Provider Demographics
NPI:1588799837
Name:KANNER, ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:KANNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E MAIN ST
Mailing Address - Street 2:SUITE 3-8
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2923
Mailing Address - Country:US
Mailing Address - Phone:631-351-3436
Mailing Address - Fax:
Practice Address - Street 1:205 E MAIN ST
Practice Address - Street 2:SUITE 3-8
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2923
Practice Address - Country:US
Practice Address - Phone:631-351-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
V15921Medicare PIN