Provider Demographics
NPI:1003170150
Name:MACCHIA, ELISA SUE (MASTERS)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:SUE
Last Name:MACCHIA
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4319
Mailing Address - Country:US
Mailing Address - Phone:631-793-4871
Mailing Address - Fax:
Practice Address - Street 1:36 MEADOW AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4319
Practice Address - Country:US
Practice Address - Phone:631-793-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health