Provider Demographics
NPI:1457716474
Name:SMITH, ELLEN CRYSTAL
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CRYSTAL
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107-41 VAN WYCK EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:917-828-6299
Mailing Address - Fax:
Practice Address - Street 1:107-41 VAN WYCK EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:917-828-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health