Individual
CARILYN CLAIRE ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSYD, MSCP
Contact information
Practice address
3857 WOLVERINE ST NE STE 6, SALEM, OR 97305-4274
(503) 856-6430
(503) 877-1920
Mailing address
920 SW RANGE DRIVE, WALDPORT, OR 97394-3035
(541) 563-3197
(541) 563-6027
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
2595
OR
103TB0200X
Cognitive & Behavioral Psychologist
2595
OR
103TC0700X
Clinical Psychologist
2595
OR
103TH0004X
Health Psychologist
2595
OR
103TP2701X
Group Psychotherapy Psychologist
2595
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R185419
MEDICARE
OR
Enumeration date
08/07/2015
Last updated
03/05/2020
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