Basic Information
| Provider Information | |||||||||
| NPI: | 1922403666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRUM | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 267 FLYE POINT RD | ||||||||
| Address2: | |||||||||
| City: | BROOKLIN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046163225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058490646 | ||||||||
| FaxNumber: | 6172543461 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 FLYE POINT RD | ||||||||
| Address2: | |||||||||
| City: | BROOKLIN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046163225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058490646 | ||||||||
| FaxNumber: | 6172543461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2014 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 21960 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 21960 | 01 | MA | MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE | OTHER | LC18429 | 01 | ME | STATE OF MAINE DEPT OF PROFESSIONAL AND FINANCIAL REGULATION | OTHER | 2584582 | 01 | MA | DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION | OTHER |