Healthcare Provider Details

I. General information

NPI: 1487659397
Provider Name (Legal Business Name): ELLEN L.H. MALONE LISW, LCSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLEN LOUISE HAMILTON PAYNE M.S.S.A.

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 HIGHWAY 90 SUITE 2
GAUTIER MS
39553-5456
US

IV. Provider business mailing address

PO BOX 1512
GAUTIER MS
39553-0019
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-8180
  • Fax: 228-497-6594
Mailing address:
  • Phone: 228-497-8180
  • Fax: 228-497-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000001199
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0003297
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC2571
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: