Provider Demographics
NPI:1164720306
Name:RUBY, ELLEN (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:RUBY
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 1:26 CLUB LN
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-2112
Mailing Address - Country:US
Mailing Address - Phone:631-725-1769
Mailing Address - Fax:631-725-1769
Practice Address - Street 1:26 CLUB LN
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-2112
Practice Address - Country:US
Practice Address - Phone:631-725-1769
Practice Address - Fax:631-725-1769
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-12
Last Update Date:2011-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCASAC2385101YA0400X
NYR-028959-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN43011Medicare PIN