Provider Demographics
NPI:1114236833
Name:CHAMBLIN, ELLEN (COTA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:CHAMBLIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 AMITYVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-1419
Mailing Address - Country:US
Mailing Address - Phone:631-650-7896
Mailing Address - Fax:
Practice Address - Street 1:346 AMITYVILLE ST
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-1419
Practice Address - Country:US
Practice Address - Phone:631-650-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000762-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant