Provider Demographics
NPI:1073746806
Name:FEDERICO, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FEDERICO
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 1:1158 GREENWICH PASS
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5880
Mailing Address - Country:US
Mailing Address - Phone:706-496-2675
Mailing Address - Fax:
Practice Address - Street 1:1050 CROWN POINTE PKWY
Practice Address - Street 2:STE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7707
Practice Address - Country:US
Practice Address - Phone:866-325-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0041141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical