Provider Demographics
NPI:1326165754
Name:CONDELLI, ELLEN M (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:CONDELLI
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 1:2201 DIGBY CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-4320
Mailing Address - Country:US
Mailing Address - Phone:919-539-7551
Mailing Address - Fax:919-861-8893
Practice Address - Street 1:146 WIND CHIME CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6433
Practice Address - Country:US
Practice Address - Phone:919-539-7551
Practice Address - Fax:919-861-8893
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0051811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2852492Medicare UPIN