Provider Demographics
NPI:1477768737
Name:STODDARD, ELLEN D (PHD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:D
Last Name:STODDARD
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 1:1455 HAMPSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3105
Mailing Address - Country:US
Mailing Address - Phone:215-545-2655
Mailing Address - Fax:
Practice Address - Street 1:1722 PINE ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6764
Practice Address - Country:US
Practice Address - Phone:215-545-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008455L103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0495987000OtherINDEPENDENCE BLUE CROSS
PA608672OtherHIGHMARK BLUE SHIELD
PA608672OtherHIGHMARK BLUE SHIELD