Provider Demographics
NPI:1245225713
Name:ROSENBERG, ELLEN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:S
Last Name:ROSENBERG
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 1:106 STERLING LN
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3230
Mailing Address - Country:US
Mailing Address - Phone:847-337-4410
Mailing Address - Fax:
Practice Address - Street 1:106 STERLING LN
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3230
Practice Address - Country:US
Practice Address - Phone:312-782-6302
Practice Address - Fax:847-251-4622
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL944670Medicare ID - Type Unspecified