Healthcare Provider Details

I. General information

NPI: 1134180474
Provider Name (Legal Business Name): ELLEN BRESSLER WAKESBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SARATOGA RD
GLENVILLE NY
12302-7110
US

IV. Provider business mailing address

113 SARATOGA RD STE 204
GLENVILLE NY
12302-7100
US

V. Phone/Fax

Practice location:
  • Phone: 518-399-0637
  • Fax: 518-399-7195
Mailing address:
  • Phone: 518-399-6741
  • Fax: 518-399-7195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPRO17658-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: