Provider Demographics
NPI:1104149616
Name:FITZGERALD-MCCALLUM, ELLEN (LICSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FITZGERALD-MCCALLUM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3224
Mailing Address - Country:US
Mailing Address - Phone:401-273-8100
Mailing Address - Fax:401-861-8696
Practice Address - Street 1:1443 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3224
Practice Address - Country:US
Practice Address - Phone:401-273-8100
Practice Address - Fax:401-861-8696
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW022901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid