Provider Demographics
NPI:1548591431
Name:HERBERT, ELLEN RUTH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:RUTH
Last Name:HERBERT
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 1:5950 FAIRVIEW RD STE 740
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3142
Mailing Address - Country:US
Mailing Address - Phone:704-457-8222
Mailing Address - Fax:
Practice Address - Street 1:5950 FAIRVIEW RD STE 740
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3142
Practice Address - Country:US
Practice Address - Phone:704-457-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-17
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NCC0084201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor