Healthcare Provider Details

I. General information

NPI: 1457946121
Provider Name (Legal Business Name): ELLIE KUPERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5309 18TH AVE
BROOKLYN NY
11204-1523
US

IV. Provider business mailing address

1295 E 34TH ST
BROOKLYN NY
11210-4819
US

V. Phone/Fax

Practice location:
  • Phone: 718-705-5190
  • Fax: 718-705-5199
Mailing address:
  • Phone: 646-320-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109093-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: