Provider Demographics
NPI:1043305436
Name:ELLROD, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ELLROD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 SALMON BROOK ST
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035
Mailing Address - Country:US
Mailing Address - Phone:860-844-8912
Mailing Address - Fax:
Practice Address - Street 1:97 SALMON BROOK ST
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035
Practice Address - Country:US
Practice Address - Phone:860-844-8912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076572Medicare ID - Type UnspecifiedGROUP ID