Provider Demographics
NPI:1922403666
Name:LANDRUM, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LANDRUM
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 1:267 FLYE POINT RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLIN
Mailing Address - State:ME
Mailing Address - Zip Code:04616-3225
Mailing Address - Country:US
Mailing Address - Phone:305-849-0646
Mailing Address - Fax:617-254-3461
Practice Address - Street 1:267 FLYE POINT RD
Practice Address - Street 2:
Practice Address - City:BROOKLIN
Practice Address - State:ME
Practice Address - Zip Code:04616-3225
Practice Address - Country:US
Practice Address - Phone:305-849-0646
Practice Address - Fax:617-254-3461
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA21960OtherMASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE
MELC18429OtherSTATE OF MAINE DEPT OF PROFESSIONAL AND FINANCIAL REGULATION
MA2584582OtherDEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION