Provider Demographics
NPI:1154526069
Name:COVIN, ELLIE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:
Last Name:COVIN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:ELLIE
Other - Middle Name:COVIN
Other - Last Name:WOLPERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:17751 78TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3770
Mailing Address - Country:US
Mailing Address - Phone:763-494-4449
Mailing Address - Fax:
Practice Address - Street 1:1405 LILAC DR N
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4535
Practice Address - Country:US
Practice Address - Phone:763-545-7708
Practice Address - Fax:763-545-3479
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4519103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent