Basic Information
| Provider Information | |||||||||
| NPI: | 1770529968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIAS | ||||||||
| FirstName: | MARCIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 271 | ||||||||
| City: | CARLE PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115141801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007256280 | ||||||||
| FaxNumber: | 8007256380 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100025601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124757755 | ||||||||
| FaxNumber: | 2124755035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0101851 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01556885 | 05 | NY | MEDICAID |