Healthcare Provider Details

I. General information

NPI: 1982977815
Provider Name (Legal Business Name): ELLEN ILENE MOLLEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7164 168TH ST
FLUSHING NY
11365-3242
US

IV. Provider business mailing address

30 W 60TH ST
NEW YORK NY
10023-7902
US

V. Phone/Fax

Practice location:
  • Phone: 718-591-8100
  • Fax: 718-969-2941
Mailing address:
  • Phone: 212-245-4412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number018337
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number018337
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: