Healthcare Provider Details

I. General information

NPI: 1952542409
Provider Name (Legal Business Name): DEBORAH LYNN ELLSWORTH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 AMITY ROAD
BETHANY CT
06524
US

IV. Provider business mailing address

649 AMITY ROAD UNIT 103
BETHANY CT
06524
US

V. Phone/Fax

Practice location:
  • Phone: 203-530-2852
  • Fax: 203-891-6128
Mailing address:
  • Phone: 203-530-2852
  • Fax: 203-891-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003980
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: