Provider Demographics
NPI:1982693412
Name:ELLIS, SUSAN O'KEEFFE (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:O'KEEFFE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:907 DREW LANE
Mailing Address - Street 2:
Mailing Address - City:ST. JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-3310
Mailing Address - Country:US
Mailing Address - Phone:516-996-3892
Mailing Address - Fax:
Practice Address - Street 1:111 SMITHTOWN BYPASS
Practice Address - Street 2:SUITE 108
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2512
Practice Address - Country:US
Practice Address - Phone:516-996-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040240-11041C0700X
NY0402401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04228126Medicaid
10476641OtherCAQH