Richard G. Ellsworth, PHD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY10083 Issued in CA

Practice address

3549 N University Ave - Suite 200
Jamestown Square -- Yorktown BLDG
Provo, UT 84604-4417

Phone

(801) 377-2014

Fax

(801) 374-7449

NPI assigned

Jan 8, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612915200000",
    "number": "1598814964",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1392 TURF FARM WAY STE 1-134",
            "city": "PAYSON",
            "state": "UT",
            "postal_code": "846515587",
            "telephone_number": "661-609-0341"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3549 N UNIVERSITY AVE - SUITE 200",
            "address_2": "JAMESTOWN SQUARE -- YORKTOWN BLDG",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846044417",
            "telephone_number": "801-377-2014",
            "fax_number": "801-374-7449"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLSWORTH",
        "first_name": "RICHARD",
        "middle_name": "G.",
        "name_prefix": "Dr.",
        "credential": "PHD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-01-08",
        "last_updated": "2021-02-10",
        "certification_date": "2021-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY10083",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "11211945-2501",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "PSY10083",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brynna Boettcher Ellison
• Charles Ellison
• Ellsworth Foot and Ankle
• Ellsworth Foot and Ankle Clinic
• Randal N Ellsworth, MD
• Shirley B Ellsworth, NP
• Allison Elmont
• Cami Emal, ACMHC
• Kristine Emanuelson
• Wendy Emerick

• Clinical Psychologist in Provo, UT
• Providers in Provo, UT by specialty
• Clinical Psychologist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.