Provider Demographics
NPI:1376702373
Name:DALE, ELLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2711 E COAST HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2711 E COAST HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2104
Practice Address - Country:US
Practice Address - Phone:949-675-2922
Practice Address - Fax:949-675-2992
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist