Provider Demographics
NPI:1750687521
Name:EZELL, DAVID L (LPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:EZELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3514
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10008-3514
Mailing Address - Country:US
Mailing Address - Phone:203-883-0464
Mailing Address - Fax:203-883-0464
Practice Address - Street 1:39 SHERMAN CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5852
Practice Address - Country:US
Practice Address - Phone:203-883-0464
Practice Address - Fax:203-883-0464
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60112655101YM0800X, 101YP2500X, 101Y00000X
CT2481101YM0800X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor