Basic Information
| Provider Information | |||||||||
| NPI: | 1932439866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RELLA | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUBIO | ||||||||
| OtherFirstName: | ELYSE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7812 35TH AVE | ||||||||
| Address2: | APT. 2M | ||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113722566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3477386798 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3722 82ND ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113727032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791600 | ||||||||
| FaxNumber: | 7188030895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2009 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 076385 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.