Provider Demographics
NPI:1225215544
Name:ELLETT, SARA O (PH D)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:O
Last Name:ELLETT
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 RANDOLPH RD
Mailing Address - Street 2:SUITE 411
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2351
Mailing Address - Country:US
Mailing Address - Phone:704-366-3400
Mailing Address - Fax:
Practice Address - Street 1:4425 RANDOLPH RD
Practice Address - Street 2:SUITE 411
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2351
Practice Address - Country:US
Practice Address - Phone:704-366-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1577103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist