Provider Demographics
NPI:1851002067
Name:ELLISON, BRIAN DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:ELLISON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1544
Mailing Address - Country:US
Mailing Address - Phone:631-885-2738
Mailing Address - Fax:
Practice Address - Street 1:935 NORTHERN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5309
Practice Address - Country:US
Practice Address - Phone:516-487-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2023-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical