Provider Demographics
NPI:1467073833
Name:REALIGN PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:REALIGN PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:240-478-8892
Mailing Address - Street 1:1258 PIPER LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1868
Mailing Address - Country:US
Mailing Address - Phone:240-478-8892
Mailing Address - Fax:
Practice Address - Street 1:1042 E FORT UNION BLVD
Practice Address - Street 2:#1085
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1800
Practice Address - Country:US
Practice Address - Phone:801-382-8702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty