Provider Demographics
NPI:1245587542
Name:ELLSWORTH, KAREN A
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:A
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KAREN
Other - Middle Name:ANN ARNOLD
Other - Last Name:ELLSWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:555 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 WARREN RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1862
Practice Address - Country:US
Practice Address - Phone:607-257-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020295-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist