Provider Demographics
NPI:1265547681
Name:ELLENWOOD, AUDREY ERLENE (PHD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:ERLENE
Last Name:ELLENWOOD
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 1:5303 SPRING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1317
Mailing Address - Country:US
Mailing Address - Phone:419-885-4121
Mailing Address - Fax:
Practice Address - Street 1:6400 MONROE ST
Practice Address - Street 2:SUITE E
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1453
Practice Address - Country:US
Practice Address - Phone:419-885-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3998103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH023158Medicaid
OH0454Medicare UPIN
OHCP04091Medicare ID - Type Unspecified