Provider Demographics
NPI:1033585971
Name:HEBERT, ELISA (MSED)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:HEBERT
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4704
Mailing Address - Country:US
Mailing Address - Phone:718-392-2510
Mailing Address - Fax:
Practice Address - Street 1:3602 14TH ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4704
Practice Address - Country:US
Practice Address - Phone:718-392-2510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1278322174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist