Provider Demographics
NPI:1235941832
Name:ELLSWORTH, GRETCHEN (RBT)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 SAINT JOE RD APT 402
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1940
Mailing Address - Country:US
Mailing Address - Phone:574-248-2175
Mailing Address - Fax:
Practice Address - Street 1:12938 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9517
Practice Address - Country:US
Practice Address - Phone:317-815-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician