Provider Demographics
NPI:1164895140
Name:ELLIS, ELLEN (LAC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 S FREEPORT RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6145
Mailing Address - Country:US
Mailing Address - Phone:720-244-3328
Mailing Address - Fax:
Practice Address - Street 1:174 S FREEPORT RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6145
Practice Address - Country:US
Practice Address - Phone:720-244-3328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist