Provider Demographics
NPI:1659796449
Name:MARTZIAL, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MARTZIAL
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:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-1768
Mailing Address - Country:US
Mailing Address - Phone:207-878-9663
Mailing Address - Fax:207-797-6137
Practice Address - Street 1:15 SAUNDERS WAY
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4833
Practice Address - Country:US
Practice Address - Phone:207-878-9663
Practice Address - Fax:207-797-6137
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC68821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical