Basic Information
Provider Information | |||||||||
NPI: | 1720407711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLSWORTH | ||||||||
FirstName: | MADELYN | ||||||||
MiddleName: | PAIGE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24 W SERGEANT COURT DR STE 204 | ||||||||
Address2: |   | ||||||||
City: | SARATOGA SPRINGS | ||||||||
State: | UT | ||||||||
PostalCode: | 840455809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019876333 | ||||||||
FaxNumber: | 8013730639 | ||||||||
Practice Location | |||||||||
Address1: | 24 W SERGEANT COURT DR STE 204 | ||||||||
Address2: |   | ||||||||
City: | SARATOGA SPRINGS | ||||||||
State: | UT | ||||||||
PostalCode: | 840455809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019876333 | ||||||||
FaxNumber: | 8013730639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2014 | ||||||||
LastUpdateDate: | 09/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 225XP0200X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 12902170-4201 | UT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.