Provider Demographics
NPI:1164618781
Name:ELLSWORTH, KATHERINE LAURA
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LAURA
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:WARGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:
Practice Address - Street 1:10 PATEWOOD DR STE 130
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6317
Practice Address - Country:US
Practice Address - Phone:864-455-8988
Practice Address - Fax:864-525-5555
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
SC120361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical