Basic Information
| Provider Information | |||||||||
| NPI: | 1588162366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMILTON | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2545 N ELDORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833471 | ||||||||
| FaxNumber: | 5418833524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2545 N ELDORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833471 | ||||||||
| FaxNumber: | 5418833524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2018 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 175T00000X | N |
ID Information
| ID | Type | State | Issuer | Description | 1720105489 | 05 | OR | MEDICAID |