Provider Demographics
NPI:1780695064
Name:PECSOK, ELLA H (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLA
Middle Name:H
Last Name:PECSOK
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 1:2302 COLONIAL AVE SW STE G2
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3100
Mailing Address - Country:US
Mailing Address - Phone:757-375-5252
Mailing Address - Fax:
Practice Address - Street 1:2302 COLONIAL AVE SW STE G2
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3100
Practice Address - Country:US
Practice Address - Phone:757-375-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA810001737103TC0700X
VA0810001737103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007705484Medicaid
R65257Medicare UPIN
VA14106Medicare ID - Type Unspecified