Provider Demographics
NPI:1891200770
Name:ELLEN SHAW-SMITH LICSW BCN, LLC
Entity Type:Organization
Organization Name:ELLEN SHAW-SMITH LICSW BCN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SHAW-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW BCN
Authorized Official - Phone:413-582-0355
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-0622
Mailing Address - Country:US
Mailing Address - Phone:413-582-0355
Mailing Address - Fax:413-582-0411
Practice Address - Street 1:104 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9570
Practice Address - Country:US
Practice Address - Phone:413-582-0355
Practice Address - Fax:413-582-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113030261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110081474AMedicaid