Healthcare Provider Details

I. General information

NPI: 1659796449
Provider Name (Legal Business Name): ELLEN MARTZIAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SAUNDERS WAY
WESTBROOK ME
04092-4833
US

IV. Provider business mailing address

PO BOX 1768
PORTLAND ME
04104-1768
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-9663
  • Fax: 207-797-6137
Mailing address:
  • Phone: 207-878-9663
  • Fax: 207-797-6137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6882
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: