Provider Demographics
NPI:1477542066
Name:BAMBRICK, ELLEN (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:BAMBRICK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RODNEY PL
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5822
Mailing Address - Country:US
Mailing Address - Phone:516-382-6425
Mailing Address - Fax:
Practice Address - Street 1:18 RODNEY PL
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5822
Practice Address - Country:US
Practice Address - Phone:516-382-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5962101YA0400X
NYR0594641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY6261Medicare ID - Type UnspecifiedPART B PROGRAN