Healthcare Provider Details

I. General information

NPI: 1174683981
Provider Name (Legal Business Name): LAURA LYNN ELLSWORTH MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/04/2025
Certification Date: 01/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S KENMORE DR
EVANSVILLE IN
47714-7514
US

IV. Provider business mailing address

929 S KENMORE DR
EVANSVILLE IN
47714-7514
US

V. Phone/Fax

Practice location:
  • Phone: 812-760-7722
  • Fax:
Mailing address:
  • Phone: 812-760-7722
  • Fax: 812-379-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39000307A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000307A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: