Provider Demographics
NPI:1659024867
Name:INDRADJAJA, ELLYA (LMHC)
Entity type:Individual
Prefix:
First Name:ELLYA
Middle Name:
Last Name:INDRADJAJA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3089 31ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-1975
Mailing Address - Country:US
Mailing Address - Phone:646-377-9724
Mailing Address - Fax:
Practice Address - Street 1:3089 31ST ST APT 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1975
Practice Address - Country:US
Practice Address - Phone:646-377-9724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011692101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health