Provider Demographics
NPI:1497305916
Name:ELLISON, SANDRA (MSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2425
Mailing Address - Country:US
Mailing Address - Phone:347-307-3613
Mailing Address - Fax:
Practice Address - Street 1:14 SLOSSON TER
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2507
Practice Address - Country:US
Practice Address - Phone:718-273-8409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker