Provider Demographics
NPI:1912537200
Name:DR. STACY ELLIS, P.C.
Entity Type:Organization
Organization Name:DR. STACY ELLIS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:323-228-7746
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-0398
Mailing Address - Country:US
Mailing Address - Phone:323-228-7746
Mailing Address - Fax:
Practice Address - Street 1:1900 OGDEN AVE STE 106
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4284
Practice Address - Country:US
Practice Address - Phone:630-405-7265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty