Provider Demographics
NPI:1790845816
Name:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Other - Org Name:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:304-487-6121
Mailing Address - Street 1:211 HUNTER PARK
Mailing Address - Street 2:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-487-6121
Mailing Address - Fax:304-487-8741
Practice Address - Street 1:211 HUNTER PARK
Practice Address - Street 2:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-487-6121
Practice Address - Fax:304-487-8741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV988103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006182Medicaid
WV3810016706Medicaid