Provider Demographics
NPI:1770244808
Name:ELLSWORTH, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
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 1:6608 S WEST SHORE BLVD APT 2218
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-1563
Mailing Address - Country:US
Mailing Address - Phone:631-339-2721
Mailing Address - Fax:
Practice Address - Street 1:6608 S WEST SHORE BLVD APT 2218
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-1563
Practice Address - Country:US
Practice Address - Phone:631-339-2721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2022-03-14
Deactivation Date:2021-12-30
Deactivation Code:
Reactivation Date:2022-03-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician