Healthcare Provider Details

I. General information

NPI: 1013154079
Provider Name (Legal Business Name): ELLEN MARY MCLEAN LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 3RD AVE
BRONX NY
10457-2562
US

IV. Provider business mailing address

147 NEW HOLLAND VLG
NANUET NY
10954-2444
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax: 718-364-7700
Mailing address:
  • Phone: 845-623-1961
  • Fax: 718-901-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number000704
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number000704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: