Provider Demographics
NPI:1407962756
Name:ELLIS, LAURA (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
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 1:1118 FINNEGAN WAY # 104
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6622
Mailing Address - Country:US
Mailing Address - Phone:360-319-3022
Mailing Address - Fax:360-734-5471
Practice Address - Street 1:1118 FINNEGAN WAY # 104
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6622
Practice Address - Country:US
Practice Address - Phone:360-319-3022
Practice Address - Fax:360-734-5471
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002510103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8803111Medicare ID - Type Unspecified