Provider Demographics
NPI:1679159768
Name:ELLINGSON, HEATHER (PSYD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:723 E HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4715
Practice Address - Country:US
Practice Address - Phone:225-743-2202
Practice Address - Fax:225-743-2028
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2573713Medicaid
LA1503OtherSTATE LICENSE