Provider Demographics
NPI:1013447309
Name:ELLSWORTH, RYAN L (LCSW, CADC I)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:ELLSWORTH
Suffix:
Gender:
Credentials:LCSW, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:WELCHES
Mailing Address - State:OR
Mailing Address - Zip Code:97067-0729
Mailing Address - Country:US
Mailing Address - Phone:971-333-0494
Mailing Address - Fax:971-715-4185
Practice Address - Street 1:24461 E WELCHES RD
Practice Address - Street 2:
Practice Address - City:WELCHES
Practice Address - State:OR
Practice Address - Zip Code:97067-7067
Practice Address - Country:US
Practice Address - Phone:971-333-0494
Practice Address - Fax:971-715-4185
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-07-07101YA0400X
ORA4926101YM0800X
ORL85951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health