Provider Demographics
NPI:1093830986
Name:GLASS, ELLYN SUE (COTA)
Entity Type:Individual
Prefix:
First Name:ELLYN
Middle Name:SUE
Last Name:GLASS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:SUE
Other - Last Name:VORON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:24 GRAND TETON DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1790
Mailing Address - Country:US
Mailing Address - Phone:302-832-2436
Mailing Address - Fax:
Practice Address - Street 1:4949 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2068
Practice Address - Country:US
Practice Address - Phone:302-998-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU2-0000644224Z00000X
PAOP000524L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant