Provider Demographics
NPI:1073167821
Name:ELLSWORTH, JOSHUA TODD
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TODD
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9208 NW 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HESSTON
Mailing Address - State:KS
Mailing Address - Zip Code:67062-6201
Mailing Address - Country:US
Mailing Address - Phone:620-217-0295
Mailing Address - Fax:
Practice Address - Street 1:231 S 30TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6455
Practice Address - Country:US
Practice Address - Phone:580-233-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst