Individual
MS. DIANE ELLABORN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSW, LICSW
Contact information
Practice address
173 MAIN STREET, PROSPECT HARBOR, ME 04669-0067
(508) 361-1751
(207) 963-9175
Mailing address
P.O. BOX 67, 173 MAIN STREET, PROSPECT HARBOR, ME 04669-0067
(508) 361-1751
(207) 963-9175
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
104732
MA
1041C0700X
Clinical Social Worker
Primary
LICSW104732
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000000031285
—
MA
01
—
1012390
BEACON
—
01
—
118190
BHN
MA
01
—
140670
VALUE OPTIONS
MA
05
—
1890352
—
MA
01
—
304462
MAGELLAN
MA
01
—
6200635
UBH
MA
01
—
767846
TUFTS
MA
01
—
P03867
BCBS
MA
Enumeration date
10/17/2006
Last updated
09/05/2023
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