Provider Demographics
NPI:1568658615
Name:ELLISON, JOAN (PSYA)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-1101
Mailing Address - Country:US
Mailing Address - Phone:914-536-5708
Mailing Address - Fax:
Practice Address - Street 1:447 N EL MOLINO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1403
Practice Address - Country:US
Practice Address - Phone:626-577-8480
Practice Address - Fax:626-577-8978
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-22
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000388-1101YM0800X
NY000256-1102L00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst