Provider Demographics
NPI:1306674700
Name:ELLSWORTH, MKAYLA TAYLOR (LBSW, BS)
Entity type:Individual
Prefix:
First Name:MKAYLA
Middle Name:TAYLOR
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LBSW, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N BERGIN LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6729
Mailing Address - Country:US
Mailing Address - Phone:505-632-4300
Mailing Address - Fax:
Practice Address - Street 1:520 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5307
Practice Address - Country:US
Practice Address - Phone:505-634-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2024-06801041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool