Provider Demographics
NPI:1588267157
Name:ELLSWORTH, CRYSTAL L (SUDP-T)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:L
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:SUDP-T
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:218 N OAK ST STE B
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2968
Mailing Address - Country:US
Mailing Address - Phone:509-684-5867
Mailing Address - Fax:509-684-1925
Practice Address - Street 1:218 N OAK ST STE B
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2968
Practice Address - Country:US
Practice Address - Phone:509-684-5867
Practice Address - Fax:509-684-1925
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM60865562376K00000X
390200000X
WACO61154536101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program