Provider Demographics
NPI:1952917965
Name:MUDLY, ELISHA
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:MUDLY
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 1:11 CLIFFORD PL APT 4L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2664
Mailing Address - Country:US
Mailing Address - Phone:929-575-0501
Mailing Address - Fax:
Practice Address - Street 1:225 BROADWAY STE 1570
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3088
Practice Address - Country:US
Practice Address - Phone:917-628-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program