Provider Demographics
NPI:1609138122
Name:DALE, ELLEN (MS)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 WARWICK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4356
Mailing Address - Country:US
Mailing Address - Phone:718-761-8525
Mailing Address - Fax:
Practice Address - Street 1:2025 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3937
Practice Address - Country:US
Practice Address - Phone:718-447-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY588976941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist