Provider Demographics
NPI:1093070872
Name:DONNER-GUZMAN, ELISSA (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:DONNER-GUZMAN
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3300
Mailing Address - Country:US
Mailing Address - Phone:718-966-0317
Mailing Address - Fax:917-791-8248
Practice Address - Street 1:12 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3300
Practice Address - Country:US
Practice Address - Phone:718-966-0317
Practice Address - Fax:917-791-8248
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19339101YA0400X
NY73-0795741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)