Provider Demographics
NPI:1265704373
Name:ELLSWORTH, BECKY A (AAS, LCMT)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:A
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:AAS, LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 LEVESQUE ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-0752
Mailing Address - Country:US
Mailing Address - Phone:401-206-1438
Mailing Address - Fax:
Practice Address - Street 1:7 GEORGE ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4006
Practice Address - Country:US
Practice Address - Phone:401-206-1438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-04
Last Update Date:2012-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01068225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist