Provider Demographics
NPI:1194562264
Name:ELLSWORTH, STEVEN MARK (LADC/MH)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:MARK
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2468
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-2468
Mailing Address - Country:US
Mailing Address - Phone:405-517-7243
Mailing Address - Fax:
Practice Address - Street 1:800 MYRTLE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4639
Practice Address - Country:US
Practice Address - Phone:405-517-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health