Provider Demographics
NPI:1659388429
Name:MCCLOUD, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MCCLOUD
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 1:80 WOODROW RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1313
Mailing Address - Country:US
Mailing Address - Phone:718-356-0008
Mailing Address - Fax:718-356-6566
Practice Address - Street 1:80 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1313
Practice Address - Country:US
Practice Address - Phone:718-356-0008
Practice Address - Fax:718-356-6566
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00006383224Z00000X
NY006383-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00006383Medicaid