Provider Demographics
NPI:1306353818
Name:ELLIS, KIMBERLY TONINE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TONINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 WHISPERING HLS
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-1565
Mailing Address - Country:US
Mailing Address - Phone:845-798-2002
Mailing Address - Fax:
Practice Address - Street 1:101 CARPENTER PL
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3592
Practice Address - Country:US
Practice Address - Phone:845-782-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29904101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)