Provider Demographics
NPI:1922005693
Name:WEILAND, ELLEN H (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:H
Last Name:WEILAND
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 851
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-0851
Mailing Address - Country:US
Mailing Address - Phone:541-326-8989
Mailing Address - Fax:
Practice Address - Street 1:132 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2746
Practice Address - Country:US
Practice Address - Phone:541-326-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-10-21
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
ORL21501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR99945OtherJACKSON COUNTY MENTAL HEA
OR858186000OtherBC BS - L.C.S.W.
OR181580Medicaid
OR317191OtherPBH
ORJ6586OtherPACIFIC SOURCE HEALTH PN
OR181580Medicaid