Provider Demographics
NPI:1598892986
Name:MAIMAN, ELLEN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:MAIMAN
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 1:4 NADINE RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3619
Mailing Address - Country:US
Mailing Address - Phone:978-266-1344
Mailing Address - Fax:
Practice Address - Street 1:111 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4141
Practice Address - Country:US
Practice Address - Phone:978-369-1113
Practice Address - Fax:978-369-0908
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10197931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP10320OtherBCBS
MA329229OtherTRICARE
MA329229OtherTRICARE