Provider Demographics
NPI:1831354653
Name:CLEGG, CHRISTINE NICOLE (LMSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:NICOLE
Last Name:CLEGG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:NICOLE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0006
Mailing Address - Country:US
Mailing Address - Phone:212-876-7427
Mailing Address - Fax:
Practice Address - Street 1:217 E 87TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3200
Practice Address - Country:US
Practice Address - Phone:212-876-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70236053502104100000X
NY077155104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker