1598814964 NPI number — DR. RICHARD G. ELLSWORTH PHD

Table of content: DR. RICHARD G. ELLSWORTH PHD (NPI 1598814964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598814964 NPI number — DR. RICHARD G. ELLSWORTH PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLSWORTH
Provider First Name:
RICHARD
Provider Middle Name:
G.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598814964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1392 TURF FARM WAY STE 1-134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAYSON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84651-5587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-609-0341
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3549 N UNIVERSITY AVE - SUITE 200
Provider Second Line Business Practice Location Address:
JAMESTOWN SQUARE -- YORKTOWN BLDG
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-377-2014
Provider Business Practice Location Address Fax Number:
801-374-7449
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY10083 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11211945-2501 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PSY10083 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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