Provider Demographics
NPI:1760413827
Name:ELLSWORTH, KIMBERLY D (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SHIRLEY CIR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7351
Mailing Address - Country:US
Mailing Address - Phone:802-879-3545
Mailing Address - Fax:802-878-9592
Practice Address - Street 1:1 MARKET PL
Practice Address - Street 2:SUITE #27&33
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-2942
Practice Address - Country:US
Practice Address - Phone:802-878-9572
Practice Address - Fax:802-878-9592
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008564Medicaid
VTELVN3439Medicare ID - Type Unspecified