Provider Demographics
NPI:1679317606
Name:ELLSWORTH, STACIA LEIGH (LCMHC)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:LEIGH
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025 CAMERON TRACE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-1201
Mailing Address - Country:US
Mailing Address - Phone:571-234-2583
Mailing Address - Fax:
Practice Address - Street 1:4302 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6336
Practice Address - Country:US
Practice Address - Phone:910-788-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health