Provider Demographics
NPI:1003878331
Name:NELLIS, MARA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:NELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 W 54TH ST
Mailing Address - Street 2:APT 202
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 W 54TH ST
Practice Address - Street 2:APT 202
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5454
Practice Address - Country:US
Practice Address - Phone:212-252-2116
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072722-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N7T542Medicare ID - Type Unspecified