Provider Demographics
NPI:1720133093
Name:WEBER, ELLEN C (LCSW,DCSW,BCD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:WEBER
Suffix:
Gender:F
Credentials:LCSW,DCSW,BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 40TH ST
Mailing Address - Street 2:#32C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2188
Mailing Address - Country:US
Mailing Address - Phone:212-286-9556
Mailing Address - Fax:212-490-9234
Practice Address - Street 1:300 E 40TH ST
Practice Address - Street 2:#32C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2188
Practice Address - Country:US
Practice Address - Phone:212-286-9556
Practice Address - Fax:212-490-9234
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSW R016056-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY095726OtherVALUE OPTIONS
NYN5X881OtherBLUE CROSSBLUE SHIELD
NYN13601Medicare ID - Type Unspecified