Basic Information
| Provider Information | |||||||||
| NPI: | 1659785954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MABE | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | WALLACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295511090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438570111 | ||||||||
| FaxNumber: | 8438570206 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S DOCTORS DR | ||||||||
| Address2: | STE. A, B, D/E | ||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295207113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435370961 | ||||||||
| FaxNumber: | 8435370908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10797 | SC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LW1023 | 05 | SC | MEDICAID |