Provider Demographics
NPI:1790009058
Name:ELLIS, CYNTHIA MARIE (LCSW,CASAC)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW,CASAC
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:MARIE
Other - Last Name:ELLIS-ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW,CASAC
Mailing Address - Street 1:1545 ATLANTIC AVENUE
Mailing Address - Street 2:INTERFAITH MEDICAL CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213
Mailing Address - Country:US
Mailing Address - Phone:718-613-4330
Mailing Address - Fax:718-613-4377
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:4TH FLOOR MICA UNIT
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-4330
Practice Address - Fax:718-613-4377
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0725331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical