Provider Demographics
NPI:1114542206
Name:BAKER, ELLISA LONG (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELLISA
Middle Name:LONG
Last Name:BAKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 BOLES RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:AL
Mailing Address - Zip Code:35750-8429
Mailing Address - Country:US
Mailing Address - Phone:256-585-4786
Mailing Address - Fax:
Practice Address - Street 1:4900 UNIVERSITY SQ STE 24
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-1829
Practice Address - Country:US
Practice Address - Phone:256-387-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5202225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics