Provider Demographics
NPI:1972573491
Name:ELLERD, RUTH ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ANNE
Last Name:ELLERD
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 1:28 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-1518
Mailing Address - Country:US
Mailing Address - Phone:631-375-5663
Mailing Address - Fax:631-473-0733
Practice Address - Street 1:28 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-1518
Practice Address - Country:US
Practice Address - Phone:631-375-5663
Practice Address - Fax:631-473-0733
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055718-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02-53-9427Medicaid
NYNC4061Medicare PIN