Provider Demographics
NPI:1245532068
Name:ELLSWORTH, TABITHA ROBIN (DC)
Entity type:Individual
Prefix:DR
First Name:TABITHA
Middle Name:ROBIN
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 NAMEOKI RD
Mailing Address - Street 2:UNIT E
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3711
Mailing Address - Country:US
Mailing Address - Phone:618-451-8830
Mailing Address - Fax:866-912-2457
Practice Address - Street 1:3701 NAMEOKI RD
Practice Address - Street 2:UNIT E
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3711
Practice Address - Country:US
Practice Address - Phone:618-451-8830
Practice Address - Fax:866-912-2457
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011457111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038011457Medicaid
ILIL4409Medicare PIN