Provider Demographics
NPI:1033980651
Name:PINANZU, ELLSON FORTI SR (PSYD)
Entity Type:Individual
Prefix:
First Name:ELLSON
Middle Name:FORTI
Last Name:PINANZU
Suffix:SR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HAMMOND ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-4474
Mailing Address - Country:US
Mailing Address - Phone:443-736-9169
Mailing Address - Fax:
Practice Address - Street 1:310 HAMMOND ST STE 104
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-4474
Practice Address - Country:US
Practice Address - Phone:443-736-9169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRSA-01150311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home