Richenel Samuel Ellecom, PSY.D; DR.P.H

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

164-2611 Issued in IL

Practice address

621 Plainfield Rd
Suite 110
Willow Brook, IL 60527-5343

Phone

(630) 654-1377

Fax

(630) 654-2575

NPI assigned

Sep 12, 2005

Last updated

Oct 27, 2008By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Institute for Health Behavior Change Inc.

  • Clinical Neuropsychologist
  • Willowbrook, IL
  • NPI 1639350044
  Authorized official Same address or phone
• Associated Behavioral Therapeutics Inc

  • Psychologist
  • Chicago, IL
  • NPI 1609897974
  NPD (past)
• Autumn Healthcare of Illinois

  • Mental Health Counselor
  • Chicago, IL
  • NPI 1679628705
  NPD (past)
• Elite Community Mental Health Center

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Chicago, IL
  • NPI 1194779181
  NPD (past)
• Clark Nursing and Rehabilitation Center, LLC

  dba Clark Nursing and Rehabilitation Center

  • Skilled Nursing Facility
  • Gary, IN
  • NPI 1114046463
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1126483200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1225065600000",
    "number": "1063406569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "621 PLAINFIELD RD",
            "address_2": "SUITE 110",
            "city": "WILLOW BROOK",
            "state": "IL",
            "postal_code": "605275343",
            "telephone_number": "630-654-1377",
            "fax_number": "630-654-2575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "621 PLAINFIELD RD",
            "address_2": "SUITE 110",
            "city": "WILLOW BROOK",
            "state": "IL",
            "postal_code": "605275343",
            "telephone_number": "630-654-1377",
            "fax_number": "630-654-2575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLECOM",
        "first_name": "RICHENEL",
        "middle_name": "SAMUEL",
        "name_prefix": "Dr.",
        "credential": "PSY.D; DR.P.H",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-09-12",
        "last_updated": "2008-10-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "IL",
            "license": "71-5240",
            "primary": false
        },
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "IN",
            "license": "20040961A",
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "IL",
            "license": "164-2611",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200909210A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200078600",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lee Marcia Eichhorn, CNM
• Elizabeth Marie Einig, MSW
• Nagla A. Bashir El Zinad
• Ahmed Elborno, MD
• Elizabeth Eliason, MS, CCC-SLP
• Ellis J Talbert, MD SC
• Hany Eskander, DPT, MS
• Patrice Evans
• Asad Farooq, DMD
• Marilee Feldman, LCPC

• Registered Dietitian in Willowbrook, IL
• Providers in Willowbrook, IL by specialty
• Registered Dietitian in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 27, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.