Provider Demographics
NPI:1538208434
Name:GREGG (QUINCE), EL'LISA RENEE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:EL'LISA
Middle Name:RENEE
Last Name:GREGG (QUINCE)
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3536
Mailing Address - Country:US
Mailing Address - Phone:315-476-7921
Mailing Address - Fax:
Practice Address - Street 1:251 SALINA MEADOWS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4584
Practice Address - Country:US
Practice Address - Phone:315-464-2096
Practice Address - Fax:315-464-2010
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068768104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker