Provider Demographics
NPI:1235342171
Name:ELLENBERG, DALE B (MS OTRL)
Entity Type:Individual
Prefix:MS
First Name:DALE
Middle Name:B
Last Name:ELLENBERG
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7308 BRYAN ST
Mailing Address - Street 2:1ST FL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1634
Mailing Address - Country:US
Mailing Address - Phone:215-284-4256
Mailing Address - Fax:267-297-7527
Practice Address - Street 1:7308 BRYAN ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1634
Practice Address - Country:US
Practice Address - Phone:215-284-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XG0600X
PAOC001722L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019385020004Medicaid