Healthcare Provider Details

I. General information

NPI: 1366383101
Provider Name (Legal Business Name): HEATHER ANN ELISOFON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 W ELIZABETH ST
WATERLOO NY
13165-1115
US

IV. Provider business mailing address

17 W ELIZABETH ST
WATERLOO NY
13165-1115
US

V. Phone/Fax

Practice location:
  • Phone: 315-224-0986
  • Fax:
Mailing address:
  • Phone: 315-224-0986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number124831
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: