Healthcare Provider Details

I. General information

NPI: 1396127932
Provider Name (Legal Business Name): ELLEN CONWAY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FORTUNE ROAD
WEST MIDDLETOWN NY
10941
US

IV. Provider business mailing address

15 FORTUNE ROAD
WEST MIDDLETOWN NY
10941
US

V. Phone/Fax

Practice location:
  • Phone: 845-673-7123
  • Fax:
Mailing address:
  • Phone: 845-673-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number049101-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: