Provider Demographics
NPI:1912523945
Name:ELLENBOGEN, DONNA ELISE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:ELISE
Last Name:ELLENBOGEN
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 1:51 WESTMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4230
Mailing Address - Country:US
Mailing Address - Phone:917-612-2720
Mailing Address - Fax:
Practice Address - Street 1:152 E 84TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2025
Practice Address - Country:US
Practice Address - Phone:917-612-2720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC852100001041C0700X
NY078097-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical