Provider Demographics
NPI:1407065196
Name:MUIR, ELLEN JO (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JO
Last Name:MUIR
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 1:129 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1803
Mailing Address - Country:US
Mailing Address - Phone:510-383-5063
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 125C
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2415
Practice Address - Country:US
Practice Address - Phone:510-383-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS140541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical