MEDICARE: ELLEN SCOTT BALTUS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L3968	OR

General Provider Information

NPI Number	:	1619255379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN SCOTT BALTUS LCSW

Provider Business Mailing Address
First Line	:	6415 SE 18TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5525
Country	:	US
Telephone Number	:	503-490-7353
Fax Number	:

Provider Business Practice Location Address
First Line	:	6415 SE 18TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5525
Country	:	US
Telephone Number	:	503-490-7353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2011
Last Update Date	:	07/29/2011

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