Provider Demographics
NPI:1770639965
Name:ELLSWORTH, KRISTY J (CMT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:J
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:J
Other - Last Name:BORDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:3212 CENTENNIAL OAK CT
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-2900
Mailing Address - Country:US
Mailing Address - Phone:810-687-0941
Mailing Address - Fax:
Practice Address - Street 1:3212 CENTENNIAL OAK CT
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-2900
Practice Address - Country:US
Practice Address - Phone:810-687-0941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMASSAGE THERAPIST171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor