Healthcare Provider Details

I. General information

NPI: 1396990792
Provider Name (Legal Business Name): ELLEN PAIGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 LIDO BLVD APT 1B
LIDO BEACH NY
11561-5201
US

IV. Provider business mailing address

750 LIDO BLVD APT 1B
LIDO BEACH NY
11561-5201
US

V. Phone/Fax

Practice location:
  • Phone: 516-456-4611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number055191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: