MEDICARE: ELIZABETH A EZELL LICSW

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	1041C0700X	Clinical Social Worker	LW60906916	WA

General Provider Information

NPI Number	:	1205435120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH A EZELL LICSW

Provider Business Mailing Address
First Line	:	6208 S MASON AVE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-1642
Country	:	US
Telephone Number	:	253-579-5718
Fax Number	:	949-577-4199

Provider Business Practice Location Address
First Line	:	4002 S M ST STE G
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-579-5718
Fax Number	:

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

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	04/14/2025

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