Provider Demographics
NPI:1962482703
Name:ELLIS, KATHRYN LOUISE (EDD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LOUISE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4457
Mailing Address - Country:US
Mailing Address - Phone:717-243-1896
Mailing Address - Fax:717-243-5297
Practice Address - Street 1:26 STATE AVE
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-4457
Practice Address - Country:US
Practice Address - Phone:717-243-1896
Practice Address - Fax:717-243-5297
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006110L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist