Provider Demographics
NPI:1689011926
Name:KRUTULESKI, ELLISHA ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLISHA
Middle Name:ELLEN
Last Name:KRUTULESKI
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 44
Mailing Address - Street 2:
Mailing Address - City:WEST KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04094-0044
Mailing Address - Country:US
Mailing Address - Phone:207-939-2127
Mailing Address - Fax:207-799-4588
Practice Address - Street 1:836 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2740
Practice Address - Country:US
Practice Address - Phone:207-939-2127
Practice Address - Fax:207-799-4588
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC154331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical