Provider Demographics
NPI:1821141722
Name:ELLIS, NAOMI (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:NAOMI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-6234
Mailing Address - Country:US
Mailing Address - Phone:516-486-0242
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD RM 6111
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-3239
Practice Address - Fax:212-939-3238
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0331031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246108Medicaid