1487659397 NPI number — ELLEN L.H. MALONE LISW, LCSW, ACSW

Table of content: ELLEN L.H. MALONE LISW, LCSW, ACSW (NPI 1487659397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487659397 NPI number — ELLEN L.H. MALONE LISW, LCSW, ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALONE
Provider First Name:
ELLEN
Provider Middle Name:
L.H.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW, LCSW, ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAYNE
Provider Other First Name:
ELLEN
Provider Other Middle Name:
LOUISE HAMILTON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.S.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487659397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAUTIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39553-0019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-497-8180
Provider Business Mailing Address Fax Number:
228-497-6594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 HIGHWAY 90
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
GAUTIER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39553-5456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-497-8180
Provider Business Practice Location Address Fax Number:
228-497-6594
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LSW0000001199 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: I-0003297 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C2571 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00802799 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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