Provider Demographics
NPI:1720015951
Name:LEWIS, ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:LEWIS
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 1:2 HAMILL RD
Mailing Address - Street 2:SUITE 326 C
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1813
Mailing Address - Country:US
Mailing Address - Phone:410-433-1118
Mailing Address - Fax:
Practice Address - Street 1:2 HAMILL RD
Practice Address - Street 2:SUITE 326 C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-1813
Practice Address - Country:US
Practice Address - Phone:410-433-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCT2180001OtherBLUE CROSS BLUE SHIELD
MDT2180001OtherBLUE CROSS BLUE SHIELD
MDGG82Medicare ID - Type Unspecified