Provider Demographics
NPI:1861423873
Name:ELLSWORTH PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:ELLSWORTH PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-879-3545
Mailing Address - Street 1:201 SHIRLEY CIR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7351
Mailing Address - Country:US
Mailing Address - Phone:802-879-3545
Mailing Address - Fax:802-878-9592
Practice Address - Street 1:1 MARKET PL
Practice Address - Street 2:SUITE #33
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-2942
Practice Address - Country:US
Practice Address - Phone:802-878-9572
Practice Address - Fax:802-878-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003140261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008564Medicaid
VTELVN3439Medicare ID - Type Unspecified