Provider Demographics
NPI:1558035071
Name:ELLEDGE, DANIEL KURODA (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KURODA
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5096
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-8974
Mailing Address - Fax:
Practice Address - Street 1:7910 FROST ST STE 195
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2897
Practice Address - Country:US
Practice Address - Phone:858-966-8974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-07
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38812103T00000X, 103TC2200X
CAPSY35268103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical