Healthcare Provider Details

I. General information

NPI: 1164838116
Provider Name (Legal Business Name): ANNALIESE DIANNA ELLSWORTH LCSW, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 NW 3RD AVE STE BANDC
CANBY OR
97013
US

IV. Provider business mailing address

7100 SW HAMPTON ST STE 128&129
TIGARD OR
97223-8315
US

V. Phone/Fax

Practice location:
  • Phone: 503-342-2510
  • Fax: 503-406-2637
Mailing address:
  • Phone: 503-342-2510
  • Fax: 503-406-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7267
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: