Provider Demographics
NPI:1497833321
Name:CLARK, ELLEN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:FLANAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD & LCSW
Mailing Address - Street 1:5 PETER COOPER RD
Mailing Address - Street 2:APT.14 F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6622
Mailing Address - Country:US
Mailing Address - Phone:212-228-7363
Mailing Address - Fax:212-473-8211
Practice Address - Street 1:2201 BERGENLINE AVE
Practice Address - Street 2:2ND FLOOR THERAPEUTIC NURSERY
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-3582
Practice Address - Country:US
Practice Address - Phone:201-558-3735
Practice Address - Fax:201-392-5048
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00132200103T00000X
NY009278103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist