Provider Demographics
NPI:1720370307
Name:ELLSWORTH, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8206 MERIDIAN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-4529
Mailing Address - Country:US
Mailing Address - Phone:609-947-6585
Mailing Address - Fax:
Practice Address - Street 1:10117 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3425
Practice Address - Country:US
Practice Address - Phone:425-806-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60219377225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist