Active NPI
Ellen M Sundberg, PH.D.
- Psychologist
- Hattiesburg, MS
National Provider Identifier
1194949602
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 34 560
- Practice address
- 312 S 25TH Ave
Hattiesburg, MS 39401-7301 - Phone
- (601) 296-1295
- Fax
- (601) 296-0119
- NPI assigned
- Apr 13, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 34 560 | MS | Primary |
Addresses
Primary practice location
312 S 25TH Ave
Hattiesburg, MS 39401-7301
Mailing address
PO Box 17743
Hattiesburg, MS 39404-7743
Phone (601) 296-1295
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0115948 | Medicaid | MS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 34 560 | MS | MD | Psychologist |
| 2881 | OR | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176422400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1227657600000",
"number": "1194949602",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 17743",
"city": "HATTIESBURG",
"state": "MS",
"postal_code": "394047743",
"telephone_number": "601-296-1295",
"fax_number": "601-296-0119"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "312 S 25TH AVE",
"city": "HATTIESBURG",
"state": "MS",
"postal_code": "394017301",
"telephone_number": "601-296-1295",
"fax_number": "601-296-0119"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SUNDBERG",
"first_name": "ELLEN",
"middle_name": "M",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-13",
"last_updated": "2008-11-26",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MS",
"license": "34 560",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0115948",
"state": "MS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Hattiesburg, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 26, 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.