Provider Demographics
NPI:1073160206
Name:ELLSWORTH, PAIGE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:BACHELOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:113 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2411
Mailing Address - Country:US
Mailing Address - Phone:517-990-6211
Mailing Address - Fax:517-990-6212
Practice Address - Street 1:3108 E MICHIGAN AVE STE A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4642
Practice Address - Country:US
Practice Address - Phone:517-268-9040
Practice Address - Fax:517-268-9042
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist