Provider Demographics
NPI:1316008352
Name:ANTCZAK, ELISSE MARIE (LCSWR)
Entity Type:Individual
Prefix:
First Name:ELISSE
Middle Name:MARIE
Last Name:ANTCZAK
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 SHERIDAN DRIVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SNYDER
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-238-0829
Mailing Address - Fax:716-898-8802
Practice Address - Street 1:3960 HARLEM RD STE 10
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:NY
Practice Address - Zip Code:14226-4706
Practice Address - Country:US
Practice Address - Phone:716-238-0829
Practice Address - Fax:716-898-8802
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR048061-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6211545OtherINDEPENDENT HEALTH
NY00026849603OtherUNIVERA
NY000526673002OtherBLUE CROSS & BLUE SHIELD