Provider Demographics
NPI:1598081275
Name:ELLSWORTH, RICHARD LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 E. INDIAN SCHOOL ROAD
Mailing Address - Street 2:STE 125
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250
Mailing Address - Country:US
Mailing Address - Phone:480-951-6451
Mailing Address - Fax:480-951-6464
Practice Address - Street 1:8115 E. INDIAN SCHOOL RD.
Practice Address - Street 2:STE 125
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250
Practice Address - Country:US
Practice Address - Phone:480-951-6451
Practice Address - Fax:480-951-6464
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant