Mary Anne Ellis, JD,PSYD

Primary specialty

Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X

License

0810004323 Issued in VA

Practice address

133 Park St NE
Vienna, VA 22180-4602

Phone

(703) 281-2657

Fax

(703) 242-0014

NPI assigned

Oct 18, 2010

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

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.

Opted out of Medicare

Yes, effective Apr 1, 2018 through Apr 1, 2028

Medicare enrollment (NPD)

Not enrolled

Credentials

Juris Doctor

State licenses

Practice roles

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.

• Womens Center

  • Clinical Social Worker
  • Vienna, VA
  • NPI 1164527859
  NPD (past)

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

{
    "created_epoch": "1287360000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1287360000000",
    "number": "1972813467",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "133 PARK ST NE",
            "city": "VIENNA",
            "state": "VA",
            "postal_code": "221804602",
            "telephone_number": "703-281-2657",
            "fax_number": "703-242-0014"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "133 PARK ST NE",
            "city": "VIENNA",
            "state": "VA",
            "postal_code": "221804602",
            "telephone_number": "703-281-2657",
            "fax_number": "703-242-0014"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "MARY",
        "middle_name": "ANNE",
        "name_prefix": "Dr.",
        "credential": "JD,PSYD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-10-18",
        "last_updated": "2010-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "VA",
            "license": "0810004323",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mohammad Elkhateeb, DDS
• Elle Dental PC
• Gary Ellenbogen, D.D.S.
• Rebecca Elliott
• Kathryn Krueger Ellis, N.P.
• Rebecca Ellison, LCSW
• Dania Elmardi
• Aya Adel Eltahir, LCSW
• Phaedra M Eltawila Almajid
• Marcus Oliver Emad, DDS

• Clinical Child & Adolescent Psychologist in Vienna, VA
• Providers in Vienna, VA by specialty
• Clinical Child & Adolescent Psychologist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2010; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.