Provider Demographics
NPI:1992063184
Name:ELLEDGE, LAWRENCE CHRISTIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:CHRISTIAN
Last Name:ELLEDGE
Suffix:
Gender:M
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:UNIVERSITY OF TENNESSEE
Mailing Address - Street 2:1404 CIRCLE DRIVE, AUSTIN PEAY, 301F
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37996-4503
Mailing Address - Country:US
Mailing Address - Phone:865-974-1958
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF TENNESSEE
Practice Address - Street 2:1404 CIRCLE DRIVE, AUSTIN PEAY, 301F
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37996-4503
Practice Address - Country:US
Practice Address - Phone:865-974-1958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LP1978103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical