Provider Demographics
NPI:1760720098
Name:ELLIS, NADYNE T (LMSW)
Entity Type:Individual
Prefix:MS
First Name:NADYNE
Middle Name:T
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 1:46 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3815
Mailing Address - Country:US
Mailing Address - Phone:516-812-3946
Mailing Address - Fax:
Practice Address - Street 1:46 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-3815
Practice Address - Country:US
Practice Address - Phone:516-812-3946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082852104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker