Provider Demographics
NPI:1710063037
Name:RICHARDS, ELLEN D (MED)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:D
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2137
Mailing Address - Country:US
Mailing Address - Phone:207-712-0498
Mailing Address - Fax:
Practice Address - Street 1:257 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2137
Practice Address - Country:US
Practice Address - Phone:207-712-0498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMF496106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME018261OtherANTHEM