Provider Demographics
NPI:1144401407
Name:FORTIN, ELLEN A (ED CEIS)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:A
Last Name:FORTIN
Suffix:
Gender:F
Credentials:ED CEIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 MARJAC RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-3448
Mailing Address - Country:US
Mailing Address - Phone:508-339-9795
Mailing Address - Fax:
Practice Address - Street 1:38 MARJAC RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-3448
Practice Address - Country:US
Practice Address - Phone:508-339-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist