Provider Demographics
NPI:1164838116
Name:ELLSWORTH, ANNALIESE DIANNA (LCSW, MSW)
Entity Type:Individual
Prefix:
First Name:ANNALIESE
Middle Name:DIANNA
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 SW HAMPTON ST STE 128&129
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8315
Mailing Address - Country:US
Mailing Address - Phone:503-342-2510
Mailing Address - Fax:503-406-2637
Practice Address - Street 1:550 NW 3RD AVE STE BANDC
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013
Practice Address - Country:US
Practice Address - Phone:503-342-2510
Practice Address - Fax:503-406-2637
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL72671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical