Provider Demographics
NPI:1851805071
Name:ELLU, KATHERINE VICTORIA (MS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:VICTORIA
Last Name:ELLU
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2516
Mailing Address - Country:US
Mailing Address - Phone:732-465-2282
Mailing Address - Fax:973-286-0400
Practice Address - Street 1:24 COMMERCE ST STE 430
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4005
Practice Address - Country:US
Practice Address - Phone:973-286-0100
Practice Address - Fax:973-286-0400
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ010892979101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ010892979Medicaid