Provider Demographics
NPI:1073167821
Name:ELLSWORTH, JOSHUA TODD
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TODD
Last Name:ELLSWORTH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9208 NW 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HESSTON
Mailing Address - State:KS
Mailing Address - Zip Code:67062-6201
Mailing Address - Country:US
Mailing Address - Phone:620-217-0295
Mailing Address - Fax:580-596-2805
Practice Address - Street 1:231 S 30TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6455
Practice Address - Country:US
Practice Address - Phone:580-596-2800
Practice Address - Fax:580-596-2805
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OK4919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst