Healthcare Provider Details

I. General information

NPI: 1972001964
Provider Name (Legal Business Name): ANN ELLSWORTH LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANN CONNELLY LICSW

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 11/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE NORTH
WORCESTER MA
01655
US

IV. Provider business mailing address

896 HAMPTON RD
POMFRET CT
06259-2017
US

V. Phone/Fax

Practice location:
  • Phone: 774-303-6888
  • Fax:
Mailing address:
  • Phone: 617-794-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1026315
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: