Provider Demographics
NPI:1962173872
Name:ELLIS, LAUREN ROSE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ROSE
Last Name:ELLIS
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LAUREN
Other - Middle Name:ROSE
Other - Last Name:CUOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:740 MARNE HWY
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3126
Mailing Address - Country:US
Mailing Address - Phone:856-553-0769
Mailing Address - Fax:
Practice Address - Street 1:25 SLEEPY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:TABERNACLE
Practice Address - State:NJ
Practice Address - Zip Code:08088-8506
Practice Address - Country:US
Practice Address - Phone:718-873-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00652600103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist