Provider Demographics
NPI:1104874551
Name:FORTUNE, ELLA R (LBSW)
Entity type:Individual
Prefix:MS
First Name:ELLA
Middle Name:R
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:MS
Other - First Name:ELLA
Other - Middle Name:R
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 N. MAGNOLIA ST.
Mailing Address - Street 2:SWCMHC,
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-1946
Mailing Address - Country:US
Mailing Address - Phone:803-775-9364
Mailing Address - Fax:803-773-6615
Practice Address - Street 1:2244 BROWNTOWN RD
Practice Address - Street 2:SWCMHC/EMERALD CRCF
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-9664
Practice Address - Country:US
Practice Address - Phone:803-428-6052
Practice Address - Fax:803-428-5406
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3119104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker