Provider Demographics
NPI:1952542409
Name:ELLSWORTH, DEBORAH LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:LYNN
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 AMITY ROAD
Mailing Address - Street 2:UNIT 103
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524
Mailing Address - Country:US
Mailing Address - Phone:203-530-2852
Mailing Address - Fax:203-891-6128
Practice Address - Street 1:649 AMITY ROAD
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:CT
Practice Address - Zip Code:06524
Practice Address - Country:US
Practice Address - Phone:203-530-2852
Practice Address - Fax:203-891-6128
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008037431Medicaid