Provider Demographics
NPI:1275842528
Name:TIEGERMAN-FARBER, ELLENMORRIS (PHD; LMSW)
Entity Type:Individual
Prefix:DR
First Name:ELLENMORRIS
Middle Name:
Last Name:TIEGERMAN-FARBER
Suffix:
Gender:F
Credentials:PHD; LMSW
Other - Prefix:DR
Other - First Name:ELLENMORRIS
Other - Middle Name:
Other - Last Name:TIEGERMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD; LMSW
Mailing Address - Street 1:100 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2818
Mailing Address - Country:US
Mailing Address - Phone:516-609-2000
Mailing Address - Fax:516-609-2008
Practice Address - Street 1:100 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2818
Practice Address - Country:US
Practice Address - Phone:516-609-2000
Practice Address - Fax:516-609-2008
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069877-1104100000X
NY000573-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY235Z00000XMedicaid
NY104100000XMedicaid