Provider Demographics
NPI:1295048775
Name:FUQUA, ELLEN D S (MS, CAS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:D S
Last Name:FUQUA
Suffix:
Gender:F
Credentials:MS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 ROUTE 23B
Mailing Address - Street 2:EARLY CHILDHOOD LEARNING CENTER OF GREENE COUNTY
Mailing Address - City:SOUTH CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12482-1220
Mailing Address - Country:US
Mailing Address - Phone:518-622-8382
Mailing Address - Fax:
Practice Address - Street 1:2395 ROUTE 23B
Practice Address - Street 2:EARLY CHILDHOOD LEARNING CENTER OF GREENE COUNTY
Practice Address - City:SOUTH CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12482-1220
Practice Address - Country:US
Practice Address - Phone:518-622-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY539948103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool