Provider Demographics
NPI:1639289630
Name:SHROUF, ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:SHROUF
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:P.O. BOX 87
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78291
Mailing Address - Country:US
Mailing Address - Phone:210-358-9172
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:903 W MARTIN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207
Practice Address - Country:US
Practice Address - Phone:210-358-3108
Practice Address - Fax:210-358-3067
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148241604Medicaid
TXP48039Medicare UPIN
TX611739Medicare ID - Type Unspecified
TX148241604Medicaid