Provider Demographics
NPI:1053674747
Name:MOLLOY, ELISE MARIA (PHN-1)
Entity Type:Individual
Prefix:MS
First Name:ELISE
Middle Name:MARIA
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:PHN-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHARLES LINDBERGH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3683
Mailing Address - Country:US
Mailing Address - Phone:516-227-8687
Mailing Address - Fax:
Practice Address - Street 1:60 CHARLES LINDBERGH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3683
Practice Address - Country:US
Practice Address - Phone:516-228-8687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341313-1171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
17OtherTAXONOMY