Provider Demographics
NPI:1134432081
Name:ELLIS, LISA B (PSYD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 303D
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6382
Mailing Address - Country:US
Mailing Address - Phone:484-838-5855
Mailing Address - Fax:610-433-5751
Practice Address - Street 1:1251 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 303D
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6382
Practice Address - Country:US
Practice Address - Phone:484-838-5855
Practice Address - Fax:610-433-5751
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016670103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist