Provider Demographics
NPI:1801823034
Name:CANCELLARA, ELIZABETH ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:CANCELLARA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 LARKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5914
Mailing Address - Country:US
Mailing Address - Phone:718-525-1000
Mailing Address - Fax:
Practice Address - Street 1:179TH STREET LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11425
Practice Address - Country:US
Practice Address - Phone:718-526-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR05077211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical