Provider Demographics
NPI:1285261230
Name:ELLSWORTH, MELISSA (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3349 S COPPER BEND RD
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-3614
Mailing Address - Country:US
Mailing Address - Phone:240-478-8892
Mailing Address - Fax:
Practice Address - Street 1:881 W BAXTER DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8506
Practice Address - Country:US
Practice Address - Phone:801-382-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11172768-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical