Basic Information
| Provider Information | |||||||||
| NPI: | 1588267157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SUDP-T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONG | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 218 N OAK ST STE B | ||||||||
| Address2: | |||||||||
| City: | COLVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991142968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096845867 | ||||||||
| FaxNumber: | 5096841925 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 N OAK ST STE B | ||||||||
| Address2: | |||||||||
| City: | COLVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991142968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096845867 | ||||||||
| FaxNumber: | 5096841925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2020 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | CM60865562 | WA | N | Nursing Service Related Providers | Nurse's Aide | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YA0400X | CO61154536 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.