Provider Demographics
NPI:1205150687
Name:ELLSWORTH, SARA MICHELLE (MA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:MICHELLE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MICHELLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1498 SKYLINE RIDGE LN SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-0413
Mailing Address - Country:US
Mailing Address - Phone:360-888-5033
Mailing Address - Fax:360-532-0061
Practice Address - Street 1:3624 ENSIGN RD NE
Practice Address - Street 2:SUITE 5
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5074
Practice Address - Country:US
Practice Address - Phone:360-412-7950
Practice Address - Fax:360-532-0061
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010745101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health