Provider Demographics
NPI:1578633350
Name:ELLIS, SUSAN G (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
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 1:3233 E BAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1900
Mailing Address - Country:US
Mailing Address - Phone:727-536-2200
Mailing Address - Fax:727-531-5088
Practice Address - Street 1:3233 E BAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-1900
Practice Address - Country:US
Practice Address - Phone:727-536-2200
Practice Address - Fax:727-531-5088
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74314ZMedicare ID - Type Unspecified