Basic Information
| Provider Information | |||||||||
| NPI: | 1306353818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | TONINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3819 WHISPERING HLS | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109181565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457982002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 CARPENTER PL | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109503592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457820295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2018 | ||||||||
| LastUpdateDate: | 01/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 29904 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.