Provider Demographics
NPI:1174034615
Name:TWIGG-PATRICK, ELLEN M (LSW: 10/17/2016)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:TWIGG-PATRICK
Suffix:
Gender:F
Credentials:LSW: 10/17/2016
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-3251
Mailing Address - Country:US
Mailing Address - Phone:732-859-8915
Mailing Address - Fax:
Practice Address - Street 1:1808 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-0873
Practice Address - Country:US
Practice Address - Phone:732-859-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SLO622600104100000X
NJ44SLO6222600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid