Provider Demographics
NPI:1124242953
Name:GUSSAROFF, ELLEN (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:GUSSAROFF
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 36TH ST
Mailing Address - Street 2:STE #1H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3465
Mailing Address - Country:US
Mailing Address - Phone:212-686-1547
Mailing Address - Fax:
Practice Address - Street 1:120 E 36TH ST
Practice Address - Street 2:STE #1H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3465
Practice Address - Country:US
Practice Address - Phone:212-686-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0281851102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst