Provider Demographics
NPI:1376193482
Name:ELLIS, KATHERYNE MAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHERYNE
Middle Name:MAE
Last Name:ELLIS
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 1:2635 RABBIT RUN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14469-9550
Mailing Address - Country:US
Mailing Address - Phone:585-749-6827
Mailing Address - Fax:
Practice Address - Street 1:2635 RABBIT RUN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NY
Practice Address - Zip Code:14469-9550
Practice Address - Country:US
Practice Address - Phone:585-749-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0134090225X00000X
NY023920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist