Provider Demographics
NPI:1902826563
Name:COLANGELO, ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:COLANGELO
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 1:3957 30TH STREET
Mailing Address - Street 2:#517
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3085
Mailing Address - Country:US
Mailing Address - Phone:619-807-5431
Mailing Address - Fax:619-291-3441
Practice Address - Street 1:3180 UNIVERSITY AVENUE
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2045
Practice Address - Country:US
Practice Address - Phone:619-807-5431
Practice Address - Fax:619-291-3441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8042827Medicaid
CAR93202Medicare UPIN