Provider Demographics
NPI:1730213554
Name:ELDER, MARY ELLEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:ELDER
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 1:211 W 56TH ST
Mailing Address - Street 2:STE. 8J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4312
Mailing Address - Country:US
Mailing Address - Phone:212-246-7533
Mailing Address - Fax:212-316-5252
Practice Address - Street 1:211 W 56TH ST
Practice Address - Street 2:STE. 8J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4312
Practice Address - Country:US
Practice Address - Phone:212-246-7533
Practice Address - Fax:212-316-5252
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR015195-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN20611Medicare ID - Type Unspecified