Individual
DR. CARL RICHARD ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ED.D.
Contact information
Practice address
4101 GRANBY ST STE 301, NORFOLK, VA 23504-1117
(757) 640-1882
(757) 640-0253
Mailing address
4101 GRANBY ST, SUITE 301, NORFOLK, VA 23504-1117
(757) 640-1882
(757) 640-0253
Taxonomy
Speciality
Code
Description
License number
State
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
0810001913
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007700580
—
VA
01
—
058231
ANTHEM BC/BS
VA
Enumeration date
10/25/2006
Last updated
06/12/2008
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