Provider Demographics
NPI:1609914217
Name:ELLIS, STEPHANIE CLARK (LAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CLARK
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 KELLARS LN
Mailing Address - Street 2:
Mailing Address - City:TILLSON
Mailing Address - State:NY
Mailing Address - Zip Code:12486-1224
Mailing Address - Country:US
Mailing Address - Phone:845-546-5358
Mailing Address - Fax:
Practice Address - Street 1:110 CREEK LOCKS RD
Practice Address - Street 2:
Practice Address - City:ROSENDALE
Practice Address - State:NY
Practice Address - Zip Code:12472-9678
Practice Address - Country:US
Practice Address - Phone:845-546-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001927171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist