Provider Demographics
NPI:1164503009
Name:ELLIS, ERICA R (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 NOTT ST E
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-4303
Mailing Address - Country:US
Mailing Address - Phone:518-372-6080
Mailing Address - Fax:518-372-6081
Practice Address - Street 1:2310 NOTT ST E
Practice Address - Street 2:
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-4303
Practice Address - Country:US
Practice Address - Phone:518-372-6080
Practice Address - Fax:518-372-6081
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008653103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54936BMedicare ID - Type Unspecified