Provider Demographics
NPI:1568510212
Name:ELLSWORTH, TIMOTHY ANDREW (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ANDREW
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3801 FAIRFAX DR STE 61
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1762
Mailing Address - Country:US
Mailing Address - Phone:571-317-1003
Mailing Address - Fax:888-220-4899
Practice Address - Street 1:3801 FAIRFAX DR 61
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1762
Practice Address - Country:US
Practice Address - Phone:571-317-1003
Practice Address - Fax:888-220-4899
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000280103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical