Provider Demographics
NPI:1578518445
Name:ELLICOTT, ABBIE M (PHD)
Entity Type:Individual
Prefix:
First Name:ABBIE
Middle Name:M
Last Name:ELLICOTT
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 1:901 DULANEY VALLEY RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2600
Mailing Address - Country:US
Mailing Address - Phone:410-832-2729
Mailing Address - Fax:
Practice Address - Street 1:901 DULANEY VALLEY RD
Practice Address - Street 2:SUITE 129
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2600
Practice Address - Country:US
Practice Address - Phone:410-832-2729
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03131103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist