Provider Demographics
NPI:1669471611
Name:ELLIOTT, STEPHEN MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MARK
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CENTRAL PARK W
Mailing Address - Street 2:SUITE 1 E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7659
Mailing Address - Country:US
Mailing Address - Phone:212-721-1523
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL PARK W
Practice Address - Street 2:SUITE 1 E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7659
Practice Address - Country:US
Practice Address - Phone:212-721-1523
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR035987-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01546170Medicaid
NYN59231Medicare ID - Type Unspecified