Provider Demographics
NPI:1821173519
Name:ELLIS, CARL RICHARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RICHARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDD
Mailing Address - Street 1:4101 GRANBY ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-1117
Mailing Address - Country:US
Mailing Address - Phone:757-640-1882
Mailing Address - Fax:757-640-0253
Practice Address - Street 1:4101 GRANBY ST STE 301
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-1117
Practice Address - Country:US
Practice Address - Phone:757-640-1882
Practice Address - Fax:757-640-0253
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001913103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA058231OtherANTHEM BC/BS
VA007700580Medicaid
VA007700580Medicaid