Provider Demographics
NPI:1659443927
Name:KONVALINKA, ELLEN PATRICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:PATRICIA
Last Name:KONVALINKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-2030
Mailing Address - Country:US
Mailing Address - Phone:914-834-3721
Mailing Address - Fax:
Practice Address - Street 1:750 ASTOR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-9304
Practice Address - Country:US
Practice Address - Phone:718-882-5000
Practice Address - Fax:718-798-7633
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072516-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN6R791Medicare ID - Type Unspecified