Provider Demographics
NPI:1669775011
Name:ELLIS, LAUREN M (PHD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:M
Last Name:ELLIS
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 1:10 GRACE AVE
Mailing Address - Street 2:OFFICE #6
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2447
Mailing Address - Country:US
Mailing Address - Phone:646-535-2641
Mailing Address - Fax:
Practice Address - Street 1:10 GRACE AVE
Practice Address - Street 2:OFFICE #6
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2447
Practice Address - Country:US
Practice Address - Phone:646-535-2641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019389-1103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling