Provider Demographics
NPI:1437915949
Name:MOORE-ELLIS, AYANNA S
Entity Type:Individual
Prefix:
First Name:AYANNA
Middle Name:S
Last Name:MOORE-ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3761
Mailing Address - Country:US
Mailing Address - Phone:516-442-1116
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CTR
Practice Address - State:NY
Practice Address - Zip Code:11570-3761
Practice Address - Country:US
Practice Address - Phone:516-442-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health