Provider Demographics
NPI:1235305376
Name:BLACK, ELLEN AUGUSTA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:AUGUSTA
Last Name:BLACK
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 1:841 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-1424
Mailing Address - Country:US
Mailing Address - Phone:814-515-4181
Mailing Address - Fax:814-317-0348
Practice Address - Street 1:841 3RD AVE
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-1424
Practice Address - Country:US
Practice Address - Phone:814-515-4181
Practice Address - Fax:814-317-0348
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW013281L104100000X
PACW0171791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021971500005Medicaid