Provider Demographics
NPI:1255091799
Name:ELLINGSWORTH, TINA RANAE (LICSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RANAE
Last Name:ELLINGSWORTH
Suffix:
Gender:F
Credentials:LICSW
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 11208
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98909-2208
Mailing Address - Country:US
Mailing Address - Phone:509-594-6310
Mailing Address - Fax:
Practice Address - Street 1:402 E YAKIMA AVE STE 800
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-5410
Practice Address - Country:US
Practice Address - Phone:509-823-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW611319371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical