Provider Demographics
NPI:1245560218
Name:ELLSWORTH, HEATHER INGE (LAC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:INGE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:INGE
Other - Last Name:HULBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 9153
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-9153
Mailing Address - Country:US
Mailing Address - Phone:406-531-0689
Mailing Address - Fax:
Practice Address - Street 1:3031 S. RUSSELL ST. STE 1
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-728-1600
Practice Address - Fax:406-327-6702
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist