Provider Demographics
NPI:1417298662
Name:FORD, ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:82 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4315
Mailing Address - Country:US
Mailing Address - Phone:631-987-2066
Mailing Address - Fax:631-581-8744
Practice Address - Street 1:111 NESCONSET HWY
Practice Address - Street 2:SUITE 108
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2524
Practice Address - Country:US
Practice Address - Phone:631-987-2066
Practice Address - Fax:631-581-8744
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078688-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical