Provider Demographics
NPI:1962888388
Name:ELLIS, CARILYN CLAIRE (PSYD, MSCP)
Entity type:Individual
Prefix:
First Name:CARILYN
Middle Name:CLAIRE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD, MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SW RANGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WALDPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97394-3035
Mailing Address - Country:US
Mailing Address - Phone:541-563-3197
Mailing Address - Fax:541-563-6027
Practice Address - Street 1:3857 WOLVERINE ST NE STE 6
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-4274
Practice Address - Country:US
Practice Address - Phone:503-856-6430
Practice Address - Fax:503-877-1920
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2595103TB0200X, 103TC0700X, 103TH0004X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR185419OtherMEDICARE