Provider Demographics
NPI:1689152233
Name:ELLIS, GWENDOLYN (LMSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13437 166TH PL APT 7C
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3812
Mailing Address - Country:US
Mailing Address - Phone:718-902-6584
Mailing Address - Fax:
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:917-344-0936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103094104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker