Provider Demographics
NPI:1932600061
Name:LARK, ELISE (PHD, LCSW, OSW-C)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:
Last Name:LARK
Suffix:
Gender:F
Credentials:PHD, LCSW, OSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 ACORN HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLIVEBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12461-5402
Mailing Address - Country:US
Mailing Address - Phone:845-657-2850
Mailing Address - Fax:845-657-2850
Practice Address - Street 1:172 ACORN HILL RD
Practice Address - Street 2:
Practice Address - City:OLIVEBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12461-5402
Practice Address - Country:US
Practice Address - Phone:845-204-4450
Practice Address - Fax:845-657-2850
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070132-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical