Provider Demographics
NPI:1598973182
Name:LORD, ELLEN (RN,MA,CAC-R,CCM)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:LORD
Suffix:
Gender:F
Credentials:RN,MA,CAC-R,CCM
Other - Prefix:MS
Other - First Name:RUTH
Other - Middle Name:ELLEN
Other - Last Name:LORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN,MA,CAC-R,CCM
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:1005 MAY STREET, SUITE A
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-0061
Mailing Address - Country:US
Mailing Address - Phone:231-883-7738
Mailing Address - Fax:231-588-7030
Practice Address - Street 1:1005 MAY ST STE A
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-9380
Practice Address - Country:US
Practice Address - Phone:231-883-7738
Practice Address - Fax:231-588-7030
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200695101YA0400X
MI4704083965163WA0400X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704083965OtherREGISTERED NURSE
MI00131110OtherCERTIFIED CASE MANAGER
MI2-00695OtherCERTIFIED ADDICTION COUNS