NPIMap

Organization Active NPI

Laurel Ridge Psychological Associates

  • Psychologist
  • Princeton, WV
National Provider Identifier
1790845816
Registry record updated Mar 20, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
988 Issued in WV
Legal business name
LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Doing business as
Laurel Ridge Psychological Associates
Practice address
211 Hunter Park
Laurel Ridge Psychological Associates
Princeton, WV 24740
Phone
(304) 487-6121
Fax
(304) 487-8741
NPI assigned
Dec 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 20, 2017

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

Authorized official

Name
Dr. David T Ellis, PSY.D.NPI 1093043754
Title
Psychologist/Partner
Phone
(304) 487-6121

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
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X 988 WV Primary

Addresses

Primary practice location

211 Hunter Park
Laurel Ridge Psychological Associates
Princeton, WV 24740

Mailing address

211 Hunter Park
Laurel Ridge Psychological Associates
Princeton, WV 24740
Phone (304) 487-6121

Other identifiers 2

IdentifierTypeStateIssuer
3810006182MedicaidWV
3810016706MedicaidWV

Other names 1

  • Laurel Ridge Psychological Associates Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170522000242 WV Part B Supplier - Clinic/Group Practice 0143542670 Receives reassigned benefits from 1 practitioner
Practice locations: Princeton, WV

National Provider Directory

National Provider Directory

Locations

211 Hunter Park
Princeton, WV 24740
Phone (304) 487-6121

199 Elmer St
Princeton, WV 24740
Phone (304) 431-2663

Practitioners & affiliated clinicians

Practitioners 5

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": "1165795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1489968000000",
    "number": "1790845816",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "211 HUNTER PARK",
            "address_2": "LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES",
            "city": "PRINCETON",
            "state": "WV",
            "postal_code": "24740",
            "telephone_number": "304-487-6121",
            "fax_number": "304-487-8741"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "211 HUNTER PARK",
            "address_2": "LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES",
            "city": "PRINCETON",
            "state": "WV",
            "postal_code": "24740",
            "telephone_number": "304-487-6121",
            "fax_number": "304-487-8741"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-11",
        "last_updated": "2017-03-20",
        "status": "A",
        "authorized_official_last_name": "ELLIS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "PSYCHOLOGIST/PARTNER",
        "authorized_official_telephone_number": "304-487-6121",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "WV",
            "license": "988",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810006182",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810016706",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Laurel Ridge Psychological Associates",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Princeton, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.