Provider Demographics
NPI:1255941936
Name:ELLEBRACHT, ANITA MARIA (EDM, MA, MA)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:MARIA
Last Name:ELLEBRACHT
Suffix:
Gender:F
Credentials:EDM, MA, MA
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:MARIA
Other - Last Name:SICIGNANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3607 28TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4579
Mailing Address - Country:US
Mailing Address - Phone:845-597-4025
Mailing Address - Fax:
Practice Address - Street 1:33 W 60TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7905
Practice Address - Country:US
Practice Address - Phone:212-333-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDLGP12532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program