Provider Demographics
NPI:1114621604
Name:ELLISON, BRUCE P SEBASTIEN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:P SEBASTIEN
Last Name:ELLISON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-4208
Mailing Address - Country:US
Mailing Address - Phone:917-861-3758
Mailing Address - Fax:
Practice Address - Street 1:1823 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1721
Practice Address - Country:US
Practice Address - Phone:631-291-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010457-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty