Provider Demographics
NPI:1124723903
Name:CLYDE, ELISABETH ANNA MULDOWNEY (LAC, R-DMT)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ANNA MULDOWNEY
Last Name:CLYDE
Suffix:
Gender:F
Credentials:LAC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 ATLANTIC AVE APT B
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-3162
Mailing Address - Country:US
Mailing Address - Phone:484-202-3104
Mailing Address - Fax:
Practice Address - Street 1:311 MARKET ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1523
Practice Address - Country:US
Practice Address - Phone:856-963-5668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2711225600000X
NJ37AC00709000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist