MEDICARE: LAURA LYNN ELLSWORTH MA, LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	39000307A	IN
2	101YM0800X	Mental Health Counselor	39000307A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11659278	OTHER	IN	CAQH PROVIDER ID

General Provider Information

NPI Number	:	1174683981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LYNN ELLSWORTH MA, LMHC

Provider Business Mailing Address
First Line	:	929 S KENMORE DR
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-7514
Country	:	US
Telephone Number	:	812-760-7722
Fax Number	:	812-379-8122

Provider Business Practice Location Address
First Line	:	929 S KENMORE DR
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-7514
Country	:	US
Telephone Number	:	812-760-7722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	01/04/2025

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