Provider Demographics
NPI:1407875172
Name:ELLICK, LAURA ALISON (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ALISON
Last Name:ELLICK
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 1:39 DEHAN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1034
Mailing Address - Country:US
Mailing Address - Phone:631-656-9507
Mailing Address - Fax:
Practice Address - Street 1:12 RENWICK AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-3709
Practice Address - Country:US
Practice Address - Phone:516-635-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014960103TC0700X, 103TB0200X, 103TE1100X, 103TP2701X, 103TC2200X, 103TH0100X, 103TH0004X, 106H00000X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily