Provider Demographics
NPI:1629113485
Name:ELLETT, SUSAN E (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:ELLETT
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 1:4535 CROATAN RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1121
Mailing Address - Country:US
Mailing Address - Phone:804-560-2891
Mailing Address - Fax:
Practice Address - Street 1:4535 CROATAN RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1121
Practice Address - Country:US
Practice Address - Phone:804-560-2891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002241103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist