Provider Demographics
NPI:1528800422
Name:KORDONOWY, ELLEN (MA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KORDONOWY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6404
Mailing Address - Country:US
Mailing Address - Phone:612-280-7159
Mailing Address - Fax:
Practice Address - Street 1:3010 3RD ST S STE C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5858
Practice Address - Country:US
Practice Address - Phone:904-853-5478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty