Active NPI
Theodore Jacob Ellenhorn, PHD
- Clinical Psychologist
- Amherst, MA
National Provider Identifier
1609911544
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 5069
- Practice address
- 17 Kellogg Ave
Ste 3
Amherst, MA 01002-2150 - Phone
- (413) 256-3075
- NPI assigned
- Feb 20, 2007
- Sex
- Male
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 5069 | MA | Primary |
Addresses
Primary practice location
17 Kellogg Ave
Ste 3
Amherst, MA 01002-2150
Mailing address
79 South Pleasant Street
Room 302
Amherst, MA 01002
Phone (413) 256-3075
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| W04790 | Other | MA | BCBS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050527000306 | MA | Practitioner - Clinical Psychologist | 0648212845 | Practice locations: Amherst, MA |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1989
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
33 Flat Hills Rd
Amherst, MA 01002-1211
Phone (413) 256-3075
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5069 | MA | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1171929600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1582588800000",
"number": "1609911544",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "79 SOUTH PLEASANT STREET",
"address_2": "ROOM 302",
"city": "AMHERST",
"state": "MA",
"postal_code": "01002",
"telephone_number": "413-256-3075"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17 KELLOGG AVE",
"address_2": "STE 3",
"city": "AMHERST",
"state": "MA",
"postal_code": "010022150",
"telephone_number": "413-256-3075"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLENHORN",
"first_name": "THEODORE",
"middle_name": "JACOB",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-02-20",
"last_updated": "2020-02-25",
"certification_date": "2020-02-25",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MA",
"license": "5069",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "W04790",
"state": "MA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Amherst, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.