Healthcare Provider Details

I. General information

NPI: 1629986252
Provider Name (Legal Business Name): LAUREN EMMA ELLSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDREN'S WAY MC 5152
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3020 CHILDREN'S WAY MC 5152
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: