Provider Demographics
NPI:1740706571
Name:ELLSWORTH, LAURA B
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:B
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 1:492 E ELIZABETH DAY CV
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5189
Mailing Address - Country:US
Mailing Address - Phone:801-661-1027
Mailing Address - Fax:801-905-1161
Practice Address - Street 1:5667 SO. REDWOOD ROAD
Practice Address - Street 2:6B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:801-905-1161
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator