Provider Demographics
NPI:1497845648
Name:FELL DEWALT, ELIZABETH H (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:FELL DEWALT
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 1:410 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901
Mailing Address - Country:US
Mailing Address - Phone:607-737-1235
Mailing Address - Fax:607-735-9617
Practice Address - Street 1:410 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901
Practice Address - Country:US
Practice Address - Phone:607-737-1235
Practice Address - Fax:607-735-9617
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012516103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA7411Medicare ID - Type Unspecified