Provider Demographics
NPI:1619046398
Name:COMSTOCK, ELLEN WARREN (MDIV, MS)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:WARREN
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:MDIV, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-2923
Mailing Address - Country:US
Mailing Address - Phone:757-623-2700
Mailing Address - Fax:757-640-1058
Practice Address - Street 1:3312 CEDAR LN
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-4104
Practice Address - Country:US
Practice Address - Phone:757-623-2700
Practice Address - Fax:757-623-2700
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701003059OtherLICENSED PROF COUNSELOR