Provider Demographics
NPI:1770906893
Name:KALLUSCH, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:KALLUSCH
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 1:7 SEAFIELD LN
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-2714
Mailing Address - Country:US
Mailing Address - Phone:631-219-7752
Mailing Address - Fax:631-730-1021
Practice Address - Street 1:7 SEAFIELD LN
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-2714
Practice Address - Country:US
Practice Address - Phone:631-219-7752
Practice Address - Fax:631-730-1021
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5463101YA0400X
NY184898163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)