Provider Demographics
NPI:1679631303
Name:ELLIS, SHIRLEY ANN (PHD ABPP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 HULSE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508-1089
Mailing Address - Country:US
Mailing Address - Phone:850-452-2783
Mailing Address - Fax:
Practice Address - Street 1:340 HULSE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-1089
Practice Address - Country:US
Practice Address - Phone:850-452-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5728103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist