Provider Demographics
NPI:1669796587
Name:ELLSWORTH, MICHELLE CRAWFORD (MS, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CRAWFORD
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 NC HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-9061
Mailing Address - Country:US
Mailing Address - Phone:252-799-7394
Mailing Address - Fax:
Practice Address - Street 1:2619 NC HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-9061
Practice Address - Country:US
Practice Address - Phone:252-799-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist