Provider Demographics
NPI:1548423569
Name:ROBERTS, ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 KELSANDO CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250
Mailing Address - Country:US
Mailing Address - Phone:360-472-0723
Mailing Address - Fax:
Practice Address - Street 1:321 PRICE ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-9606
Practice Address - Country:US
Practice Address - Phone:360-472-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000045251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB19520Medicare PIN
P25265Medicare UPIN