Active NPI
Ellis Edmunds
- Clinical Psychologist
- Oakland, CA
National Provider Identifier
1740595768
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY27058
- Practice address
- 4243 Terrace St
Oakland, CA 94611-5127 - Phone
- (510) 919-8366
- NPI assigned
- Aug 13, 2010
- Last updated
- Jul 22, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counselor | 101Y00000X | NU | ||
| Clinical Psychologist | 103TC0700X | PSY27058 | CA | Primary |
| Student in an Organized Health Care Education/Training Program | 390200000X | NU |
Addresses
Primary practice location
4243 Terrace St
Oakland, CA 94611-5127
Mailing address
4243 Terrace St
Oakland, CA 94611-5127
Phone (510) 919-8366
Other practice location 1
2500 Bissell Ave
Richmond, CA 94804-1815
Phone (510) 235-1516
Other practice location 2
5478A College Ave
Oakland, CA 94618
Phone (510) 473-5083
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY27058 | CA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1281657600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1595376000000",
"number": "1740595768",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4243 TERRACE ST",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946115127",
"telephone_number": "510-919-8366"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4243 TERRACE ST",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946115127",
"telephone_number": "510-919-8366"
}
],
"practiceLocations": [
{
"address_1": "2500 Bissell Ave",
"address_purpose": "LOCATION",
"city": "Richmond",
"state": "CA",
"postal_code": "948041815",
"country_code": "US",
"telephone_number": "510-235-1516",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "5478A College Ave",
"address_purpose": "LOCATION",
"city": "Oakland",
"state": "CA",
"postal_code": "94618",
"country_code": "US",
"telephone_number": "510-473-5083",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "EDMUNDS",
"first_name": "ELLIS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2010-08-13",
"last_updated": "2020-07-22",
"certification_date": "2020-07-22",
"status": "A"
},
"taxonomies": [
{
"code": "101Y00000X",
"taxonomy_group": "",
"desc": "Counselor",
"state": "NU",
"license": null,
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY27058",
"primary": true
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "NU",
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Oakland, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.