Provider Demographics
NPI:1528179454
Name:STURGIS, ELLIE T (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:T
Last Name:STURGIS
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 1:200 PROFESSIONAL PARK DR SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6679
Mailing Address - Country:US
Mailing Address - Phone:540-552-1402
Mailing Address - Fax:540-552-3428
Practice Address - Street 1:200 PROFESSIONAL PARK DR SE
Practice Address - Street 2:SUITE 1
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6679
Practice Address - Country:US
Practice Address - Phone:540-552-1402
Practice Address - Fax:540-552-3428
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11511730OtherCAQH CREDENTIALING ID