MEDICARE: MS. DOROTHEA ELLERN LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	008430	NY

General Provider Information

NPI Number	:	1447395934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOROTHEA ELLERN LMSW

Provider Business Mailing Address
First Line	:	90 RIVERSIDE DR
Second Line	:	APARTMENT NO. 12F
City	:	NEW YORK
State	:	NY
Zip	:	10024-5306
Country	:	US
Telephone Number	:	212-877-2087
Fax Number	:

Provider Business Practice Location Address
First Line	:	2581 ATLANTIC AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-2412
Country	:	US
Telephone Number	:	718-495-6700
Fax Number	:	718-485-4018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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