Provider Demographics
NPI:1063406569
Name:ELLECOM, RICHENEL SAMUEL (PSYD; DRPH)
Entity type:Individual
Prefix:DR
First Name:RICHENEL
Middle Name:SAMUEL
Last Name:ELLECOM
Suffix:
Gender:M
Credentials:PSYD; DRPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 PLAINFIELD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WILLOW BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5343
Mailing Address - Country:US
Mailing Address - Phone:630-654-1377
Mailing Address - Fax:630-654-2575
Practice Address - Street 1:621 PLAINFIELD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WILLOW BROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5343
Practice Address - Country:US
Practice Address - Phone:630-654-1377
Practice Address - Fax:630-654-2575
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71-5240103G00000X
IN20040961A103G00000X
IL164-2611133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200909210AMedicaid
IN200078600Medicaid
IN200078600Medicaid
IL392810Medicare PIN
IN877640AMedicare PIN