Carilyn Claire Ellis, PSYD, MSCP

Primary specialty

PsychologistTaxonomy code 103T00000X

License

2595 Issued in OR

Practice address

3857 Wolverine St NE Ste 6
Salem, OR 97305-4274

Phone

(503) 856-6430

Fax

(503) 877-1920

NPI assigned

Aug 7, 2015

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 5

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: cellis182589@direct.salemhealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Autumn Leaf Therapeutic Services

  • Community/Behavioral Health Agency
  • Salem, OR
  • NPI 1689209371

  Psychologist

  NPD Authorized official
• Samaritan Pacific Health Services, Inc.

  • Rural Health Clinic/Center
  • Waldport, OR
  • NPI 1619047503
  NPD (past)

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

{
    "created_epoch": "1438905600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1583366400000",
    "number": "1962888388",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "920 SW RANGE DRIVE",
            "city": "WALDPORT",
            "state": "OR",
            "postal_code": "973943035",
            "telephone_number": "541-563-3197",
            "fax_number": "541-563-6027"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3857 WOLVERINE ST NE STE 6",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973054274",
            "telephone_number": "503-856-6430",
            "fax_number": "503-877-1920"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "CARILYN",
        "middle_name": "CLAIRE",
        "credential": "PSYD, MSCP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-08-07",
        "last_updated": "2020-03-05",
        "certification_date": "2020-03-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TB0200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": "OR",
            "license": "2595",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "OR",
            "license": "2595",
            "primary": false
        },
        {
            "code": "103TH0004X",
            "taxonomy_group": "",
            "desc": "Psychologist, Health",
            "state": "OR",
            "license": "2595",
            "primary": false
        },
        {
            "code": "103TP2701X",
            "taxonomy_group": "",
            "desc": "Psychologist, Group Psychotherapy",
            "state": "OR",
            "license": "2595",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "OR",
            "license": "2595",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "R185419",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Robert Richard Ellestad, LMT
• Jacqueline A Elliott Vermeer, QMHA, MENTAL HEALTH
• Jude Regan Elliott, CPO
• Sean C Elliott, ANP
• Jamie Lynn Ellis - Wittenhagen, D.O.
• Chrystal Jean Ellis
• Jordyn R Ellis, CHW
• Katelynn Anne Ellis
• Robin Ellison
• William Blount Ellison III, MD

• Psychologist in Salem, OR
• Providers in Salem, OR by specialty
• Psychologist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 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.

Verify at the official NPI Registry.