Provider Demographics
NPI:1932227519
Name:ANDERSON, ELLEN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:ANDERSON
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 1:1108 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-3517
Mailing Address - Country:US
Mailing Address - Phone:419-353-3361
Mailing Address - Fax:419-874-1989
Practice Address - Street 1:836 W SOUTH BOUNDARY ST
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5200
Practice Address - Country:US
Practice Address - Phone:419-874-3201
Practice Address - Fax:419-875-1989
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE00001889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional