Provider Demographics
NPI:1760859102
Name:ELY, MARIAH CLEMENT (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARIAH
Middle Name:CLEMENT
Last Name:ELY
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 1:332 E. 84TH ST.
Mailing Address - Street 2:4D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028
Mailing Address - Country:US
Mailing Address - Phone:401-749-2696
Mailing Address - Fax:
Practice Address - Street 1:1115 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3450
Practice Address - Country:US
Practice Address - Phone:401-749-2696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084274-1104100000X
NY082641-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker