Provider Demographics
NPI:1285372870
Name:ELLENBERG, STACY (PHD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ELLENBERG
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 1:6 YARDLEY GRN
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1259
Mailing Address - Country:US
Mailing Address - Phone:508-245-2276
Mailing Address - Fax:
Practice Address - Street 1:6 YARDLEY GRN
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1259
Practice Address - Country:US
Practice Address - Phone:508-245-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112047-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical