| Carl R. Ellis | |
|
1020 Independence Blvd Suite 204 Virginia Beach VA 23455-5500 | |
| (757) 640-1882 | |
| (757) 640-0253 |
| Full Name | Carl R. Ellis |
|---|---|
| Speciality | Psychologist - Clinical Child & Adolescent |
| Location | 1020 Independence Blvd, Virginia Beach, Virginia |
| Authorized Official Name and Position | Carl Richard Ellis (OWNER) |
| Authorized Official Contact | 7576401882 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Carl R. Ellis 1020 Independence Blvd Suite 204 Virginia Beach VA 23455-5500 Ph: (757) 640-1882 | Carl R. Ellis 1020 Independence Blvd Suite 204 Virginia Beach VA 23455-5500 Ph: (757) 640-1882 |
| NPI Number | 1114002581 |
|---|---|
| Provider Enumeration Date | 10/26/2006 |
| Last Update Date | 09/04/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114002581 | NPI | - | NPPES |
| 260026000 | Other | VA | OPTIMA HEALTH |
| 007700580 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC2200X | Psychologist - Clinical Child & Adolescent | 0810001913 (Virginia) | Primary |
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