Basic Information
Provider Information | |||||||||
NPI: | 1013154079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCLEAN | ||||||||
FirstName: | ELLEN | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCAT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 147 NEW HOLLAND VLG | ||||||||
Address2: |   | ||||||||
City: | NANUET | ||||||||
State: | NY | ||||||||
PostalCode: | 109542444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456231961 | ||||||||
FaxNumber: | 7189016880 | ||||||||
Practice Location | |||||||||
Address1: | 4419 3RD AVE | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104572562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183647700 | ||||||||
FaxNumber: | 7183647700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2009 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 000704 | NY | N |   | Hospitals | Psychiatric Hospital |   | 246ZA2600X | 000704 | NY | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Art, Medical |
No ID Information.