Provider Demographics
NPI:1265548895
Name:ELLIS, CHERYL (PSYD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
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 1:2 SILO WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-1651
Mailing Address - Country:US
Mailing Address - Phone:860-242-3640
Mailing Address - Fax:
Practice Address - Street 1:11 MOUNTAIN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2343
Practice Address - Country:US
Practice Address - Phone:860-726-9457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002512103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist