Provider Demographics
NPI:1487659397
Name:MALONE, ELLEN LH (LISW, LCSW, ACSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LH
Last Name:MALONE
Suffix:
Gender:F
Credentials:LISW, LCSW, ACSW
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:LOUISE HAMILTON
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSA
Mailing Address - Street 1:PO BOX 1512
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-0019
Mailing Address - Country:US
Mailing Address - Phone:228-497-8180
Mailing Address - Fax:228-497-6594
Practice Address - Street 1:1408 HIGHWAY 90
Practice Address - Street 2:SUITE 2
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5456
Practice Address - Country:US
Practice Address - Phone:228-497-8180
Practice Address - Fax:228-497-6594
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000011991041C0700X
OHI-00032971041C0700X
MSC25711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00802799Medicaid