Healthcare Provider Details

I. General information

NPI: 1114055373
Provider Name (Legal Business Name): ELLEN ENDICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 SEMINOLE AVE
BRONX NY
10461-1807
US

IV. Provider business mailing address

5 MCKENNA PL
MAMARONECK NY
10543-2112
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-8900
  • Fax:
Mailing address:
  • Phone: 914-834-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberRO57165-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: