Provider Demographics
NPI:1942532619
Name:ELLISON, SHERRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHERRY
Middle Name:
Last Name:ELLISON
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 1:41750 RANCHO LAS PALMAS DR
Mailing Address - Street 2:SUITE L-4
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5511
Mailing Address - Country:US
Mailing Address - Phone:760-250-5433
Mailing Address - Fax:
Practice Address - Street 1:41750 RANCHO LAS PALMAS DR
Practice Address - Street 2:SUITE L-4
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-5511
Practice Address - Country:US
Practice Address - Phone:760-250-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist