Provider Demographics
NPI:1598814964
Name:ELLSWORTH, RICHARD G (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1392 TURF FARM WAY STE 1-134
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-5587
Mailing Address - Country:US
Mailing Address - Phone:661-609-0341
Mailing Address - Fax:
Practice Address - Street 1:3549 N UNIVERSITY AVE - SUITE 200
Practice Address - Street 2:JAMESTOWN SQUARE -- YORKTOWN BLDG
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4417
Practice Address - Country:US
Practice Address - Phone:801-377-2014
Practice Address - Fax:801-374-7449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10083103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11211945-2501OtherSTATE LICENSE
CAPSY10083OtherSTATE LICENSE