Provider Demographics
NPI:1033117650
Name:SWITRAS, JOSEPH ELLSWORTH (PH D LICENSED PSYC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ELLSWORTH
Last Name:SWITRAS
Suffix:
Gender:M
Credentials:PH D LICENSED PSYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W 2ND ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-1843
Mailing Address - Country:US
Mailing Address - Phone:507-235-5651
Mailing Address - Fax:507-235-5651
Practice Address - Street 1:208 W 2ND ST
Practice Address - Street 2:SUITE 116
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-1843
Practice Address - Country:US
Practice Address - Phone:507-235-5651
Practice Address - Fax:507-235-5651
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN154348200Medicaid
689000052Medicare ID - Type Unspecified