Provider Demographics
NPI:1730346792
Name:ELLIS, LESLIE ELAINE (PHD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ELAINE
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 1:207 CRYSTAL GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6452
Mailing Address - Country:US
Mailing Address - Phone:813-964-9101
Mailing Address - Fax:813-964-9141
Practice Address - Street 1:207 CRYSTAL GROVE BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-6452
Practice Address - Country:US
Practice Address - Phone:813-964-9101
Practice Address - Fax:813-964-9141
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7721103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ130QOtherBCBSF