Provider Demographics
NPI:1780896233
Name:PETTIT, ELLEN J (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:PETTIT
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 1:1621 OAK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1000
Mailing Address - Country:US
Mailing Address - Phone:530-753-6864
Mailing Address - Fax:
Practice Address - Street 1:1621 OAK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1000
Practice Address - Country:US
Practice Address - Phone:530-753-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9144103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical