Provider Demographics
NPI:1558585406
Name:EISNER, ELLIS A (MA)
Entity Type:Individual
Prefix:MS
First Name:ELLIS
Middle Name:A
Last Name:EISNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 HOMER PL
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2006
Mailing Address - Country:US
Mailing Address - Phone:718-779-1600
Mailing Address - Fax:718-396-6189
Practice Address - Street 1:3722 82ND ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7032
Practice Address - Country:US
Practice Address - Phone:718-779-1600
Practice Address - Fax:718-396-6189
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000479221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist