Provider Demographics
NPI:1023539285
Name:LAWRENCE A. ELLSWORTH, LCSW, PLLC
Entity Type:Organization
Organization Name:LAWRENCE A. ELLSWORTH, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-815-4984
Mailing Address - Street 1:5104 BRIDGET DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-9332
Mailing Address - Country:US
Mailing Address - Phone:919-815-4984
Mailing Address - Fax:
Practice Address - Street 1:8520 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3096
Practice Address - Country:US
Practice Address - Phone:919-815-4984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0010701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty