Provider Demographics
NPI:1013670868
Name:ELLIS PSYCHOTHERAPY, TRAINING & CONSULTATION
Entity Type:Organization
Organization Name:ELLIS PSYCHOTHERAPY, TRAINING & CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SYLVADRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:475-441-4082
Mailing Address - Street 1:33 DIXWELL AVE # 239
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3403
Mailing Address - Country:US
Mailing Address - Phone:475-441-4082
Mailing Address - Fax:
Practice Address - Street 1:21 FARNHAM AVE APT 1
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1265
Practice Address - Country:US
Practice Address - Phone:475-441-4082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-19
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health