Provider Demographics
NPI:1598716581
Name:WILFONG-GRUSH, ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:WILFONG-GRUSH
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 1:1569 HUTTON PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3505
Mailing Address - Country:US
Mailing Address - Phone:843-571-0601
Mailing Address - Fax:843-571-0601
Practice Address - Street 1:1744 SAM RITTENBERG BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4935
Practice Address - Country:US
Practice Address - Phone:843-763-2425
Practice Address - Fax:843-571-0601
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical