Provider Demographics
NPI:1134180474
Name:BRESSLER WAKESBERG, ELLEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:BRESSLER WAKESBERG
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 1:113 SARATOGA RD STE 204
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-7100
Mailing Address - Country:US
Mailing Address - Phone:518-399-6741
Mailing Address - Fax:518-399-7195
Practice Address - Street 1:113 SARATOGA RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-7110
Practice Address - Country:US
Practice Address - Phone:518-399-0637
Practice Address - Fax:518-399-7195
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO17658-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0528Medicare ID - Type Unspecified
NYS17036Medicare UPIN