Provider Demographics
NPI:1215017694
Name:ELLIS, KENNETH R (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 TWIN KNOLLS RD
Mailing Address - Street 2:SUITE 327
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3266
Mailing Address - Country:US
Mailing Address - Phone:410-992-9149
Mailing Address - Fax:410-992-9921
Practice Address - Street 1:5525 TWIN KNOLLS RD
Practice Address - Street 2:SUITE 327
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3266
Practice Address - Country:US
Practice Address - Phone:410-992-9149
Practice Address - Fax:410-992-9921
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1003103TC1900X
FLPY4750103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD572L894CMedicare ID - Type Unspecified