Provider Demographics
NPI:1629293352
Name:GOELL-VARKOVITZKY, ELANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELANA
Middle Name:
Last Name:GOELL-VARKOVITZKY
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 1:6279 DAKOTA CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1567
Mailing Address - Country:US
Mailing Address - Phone:248-865-1525
Mailing Address - Fax:
Practice Address - Street 1:26111 W. 14 MILE ROAD
Practice Address - Street 2:SUITE LL3
Practice Address - City:FRANKLIN VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48025-1168
Practice Address - Country:US
Practice Address - Phone:248-737-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006995103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF33025Medicare ID - Type Unspecified