Provider Demographics
NPI:1245368273
Name:WALSTON, ELLEN M
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:WALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MIXON
Other - Last Name:WALSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3219 LANDMARK ST STE 7A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7688
Mailing Address - Country:US
Mailing Address - Phone:252-355-2801
Mailing Address - Fax:252-355-4708
Practice Address - Street 1:3219 LANDMARK ST STE 7A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7688
Practice Address - Country:US
Practice Address - Phone:252-355-2801
Practice Address - Fax:252-355-4708
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002950Medicaid
NCD1613OtherMEDCOST
NC1358WOtherBCBS
NC1358WOtherBCBS