Provider Demographics
NPI:1073656310
Name:ZUCROW, ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:ZUCROW
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 1:5293 FOREST BROOK PKWY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2835
Mailing Address - Country:US
Mailing Address - Phone:770-355-9902
Mailing Address - Fax:
Practice Address - Street 1:4549 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6210
Practice Address - Country:US
Practice Address - Phone:770-677-9300
Practice Address - Fax:770-677-9400
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0031971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFZSMedicare ID - Type Unspecified