NPIMap

Organization Active NPI

Carl R. Ellis

Doing business as Spectrum Psychological Services

  • Clinical Child & Adolescent Psychologist
  • Virginia Beach, VA
National Provider Identifier
1114002581
Registry record updated Sep 4, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X
License
0810001913 Issued in VA
Legal business name
CARL R. ELLIS
Doing business as
Spectrum Psychological Services
Practice address
1020 Independence Blvd
Suite 204
Virginia Beach, VA 23455-5500
Phone
(757) 640-1882
Fax
(757) 640-0253
NPI assigned
Oct 26, 2006
Last updated
Sep 4, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 4, 2012

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

Authorized official

Name
Dr. Carl Richard Ellis, ED.D.NPI 1821173519
Title
Owner
Phone
(757) 640-1882

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Child & Adolescent Psychologist 103TC2200X 0810001913 VA Primary

Addresses

Primary practice location

1020 Independence Blvd
Suite 204
Virginia Beach, VA 23455-5500

Mailing address

1020 Independence Blvd
Suite 204
Virginia Beach, VA 23455-5500
Phone (757) 640-1882

Other identifiers 2

IdentifierTypeStateIssuer
007700580MedicaidVA
260026000OtherVAOPTIMA HEALTH

Other names 1

  • Spectrum Psychological Services Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1161820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1346716800000",
    "number": "1114002581",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1020 INDEPENDENCE BLVD",
            "address_2": "SUITE 204",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234555500",
            "telephone_number": "757-640-1882",
            "fax_number": "757-640-0253"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1020 INDEPENDENCE BLVD",
            "address_2": "SUITE 204",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234555500",
            "telephone_number": "757-640-1882",
            "fax_number": "757-640-0253"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CARL R. ELLIS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-26",
        "last_updated": "2012-09-04",
        "status": "A",
        "authorized_official_last_name": "ELLIS",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "RICHARD",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "757-640-1882",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "ED.D."
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "VA",
            "license": "0810001913",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "007700580",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OPTIMA HEALTH",
            "identifier": "260026000",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Spectrum Psychological Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Virginia Beach, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 4, 2012; 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.