Provider Demographics
NPI:1407939820
Name:SIMPAO, ELLEN B (PHD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:SIMPAO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3910
Mailing Address - Country:US
Mailing Address - Phone:718-788-4077
Mailing Address - Fax:718-788-4077
Practice Address - Street 1:14 E 4TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1155
Practice Address - Country:US
Practice Address - Phone:212-254-6028
Practice Address - Fax:718-788-4077
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14505 - 01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVL6011Medicare ID - Type Unspecified