Provider Demographics
NPI:1134866767
Name:ELLSWORTH, ALISSA CLAIRE (CSWA)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:CLAIRE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:CLAIRE
Other - Last Name:CROSSLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1904 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1146
Mailing Address - Country:US
Mailing Address - Phone:503-517-8663
Mailing Address - Fax:
Practice Address - Street 1:1904 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1146
Practice Address - Country:US
Practice Address - Phone:503-517-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
ORA139701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator