Provider Demographics
NPI:1124109459
Name:ELLABORN, DIANE (MSW, LICSW)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:ELLABORN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 67
Mailing Address - Street 2:173 MAIN STREET
Mailing Address - City:PROSPECT HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04669-0067
Mailing Address - Country:US
Mailing Address - Phone:508-361-1751
Mailing Address - Fax:207-963-9175
Practice Address - Street 1:173 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PROSPECT HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04669-0067
Practice Address - Country:US
Practice Address - Phone:508-361-1751
Practice Address - Fax:207-963-9175
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1047321041C0700X
MALICSW1047321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000031285Medicaid
MA304462OtherMAGELLAN
MA140670OtherVALUE OPTIONS
MAP03867OtherBCBS
1012390OtherBEACON
MA1890352Medicaid
MA118190OtherBHN
MA6200635OtherUBH
MA767846OtherTUFTS
MA000000031285Medicaid