Provider Demographics
NPI:1609141282
Name:ELLSWORTH, PETER JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 GARFIELD ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1368
Mailing Address - Country:US
Mailing Address - Phone:202-352-2203
Mailing Address - Fax:
Practice Address - Street 1:1350 CONNECTICUT AVE NW STE 500
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-1736
Practice Address - Country:US
Practice Address - Phone:202-790-9725
Practice Address - Fax:202-342-2415
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBU71-0001OtherCAREFIRST BLUECROSS BLUESHIELD