Provider Demographics
NPI:1609911544
Name:ELLENHORN, THEODORE JACOB (PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JACOB
Last Name:ELLENHORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 SOUTH PLEASANT STREET
Mailing Address - Street 2:ROOM 302
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002
Mailing Address - Country:US
Mailing Address - Phone:413-256-3075
Mailing Address - Fax:
Practice Address - Street 1:17 KELLOGG AVE
Practice Address - Street 2:STE 3
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2150
Practice Address - Country:US
Practice Address - Phone:413-256-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04790OtherBCBS