Healthcare Provider Details

I. General information

NPI: 1528116548
Provider Name (Legal Business Name): ELLEN RENEE ALTMAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E DIXIE AVE
LEESBURG FL
34748-6350
US

IV. Provider business mailing address

104 E DIXIE AVE
LEESBURG FL
34748-6350
US

V. Phone/Fax

Practice location:
  • Phone: 352-451-1521
  • Fax: 352-431-3173
Mailing address:
  • Phone: 352-451-1521
  • Fax: 352-431-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-06207
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: