Provider Demographics
NPI:1720510613
Name:ELLSWORTH, ELIZABETH ANNE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-1904
Mailing Address - Country:US
Mailing Address - Phone:860-351-5407
Mailing Address - Fax:860-351-5774
Practice Address - Street 1:56 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1904
Practice Address - Country:US
Practice Address - Phone:860-351-5407
Practice Address - Fax:860-351-5774
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-17-25291103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst