Provider Demographics
NPI:1851288914
Name:ELLSWORTH, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40975 N ARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-5416
Mailing Address - Country:US
Mailing Address - Phone:661-859-9873
Mailing Address - Fax:
Practice Address - Street 1:6638 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4433
Practice Address - Country:US
Practice Address - Phone:480-534-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-21
Last Update Date:2025-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-034221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist