Provider Demographics
NPI:1497308597
Name:ELLEFSEN, CORINNE ALYSE
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:ALYSE
Last Name:ELLEFSEN
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 1:208 E HARFORD ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-1042
Mailing Address - Country:US
Mailing Address - Phone:845-346-6024
Mailing Address - Fax:
Practice Address - Street 1:1300 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:PA
Practice Address - Zip Code:18433-1973
Practice Address - Country:US
Practice Address - Phone:570-281-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW136306104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker