Provider Demographics
NPI:1972969228
Name:ELLIS, SARAH GOLDBERG (LCSW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:GOLDBERG
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 ROUTE 73 N STE 11
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3456
Mailing Address - Country:US
Mailing Address - Phone:856-452-1818
Mailing Address - Fax:
Practice Address - Street 1:751 ROUTE 73 N STE 11
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3456
Practice Address - Country:US
Practice Address - Phone:856-452-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0184301041C0700X
NJ44SC055984001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223719456OtherINTEGRATIVE, TRAINING AND CONSULTING