Provider Demographics
NPI:1396851101
Name:ELLINGSTAD, TIMOTHY P (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:P
Last Name:ELLINGSTAD
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:190 GARDNER AVE
Practice Address - Street 2:#3
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2160
Practice Address - Country:US
Practice Address - Phone:262-763-7766
Practice Address - Fax:262-763-9326
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0004X
WI2452-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39142400Medicaid