Provider Demographics
NPI:1528018025
Name:MCRAE, ELLEN K (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:K
Last Name:MCRAE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 BANE RD
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9322
Mailing Address - Country:US
Mailing Address - Phone:919-630-0587
Mailing Address - Fax:
Practice Address - Street 1:355 S MADISON BLVD STE C
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5485
Practice Address - Country:US
Practice Address - Phone:919-630-0587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0015171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106168Medicaid
NC2873455Medicare PIN
NCQ42644AMedicare PIN