Provider Demographics
NPI:1912184326
Name:ELLIS, STACY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
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:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-0398
Mailing Address - Country:US
Mailing Address - Phone:323-228-7746
Mailing Address - Fax:
Practice Address - Street 1:1900 OGDEN AVE STE 106
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4284
Practice Address - Country:US
Practice Address - Phone:630-405-7265
Practice Address - Fax:630-256-8009
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010228103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical