Provider Demographics
NPI:1487014205
Name:ELLSWORTH, MANON (MS, MFT, LPC)
Entity Type:Individual
Prefix:
First Name:MANON
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MS, MFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MO
Mailing Address - Zip Code:64644-0294
Mailing Address - Country:US
Mailing Address - Phone:303-214-8054
Mailing Address - Fax:
Practice Address - Street 1:507 W MCGAUGHY ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MO
Practice Address - Zip Code:64644-1048
Practice Address - Country:US
Practice Address - Phone:303-214-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X, 103T00000X, 103TC1900X, 103TP2701X, 106H00000X, 101YP2500X
CO14663103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1487014205Medicaid