Provider Demographics
NPI:1194839308
Name:ELLSWORTH, LAWRENCE A (MSSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:A
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:919-779-2964
Mailing Address - Fax:919-212-7826
Practice Address - Street 1:8520 SIX FORKS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3095
Practice Address - Country:US
Practice Address - Phone:919-815-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC001070104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker