Provider Demographics
NPI:1437435468
Name:SMITH, ELLEN GRAY (OT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GRAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PELLETT ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1209
Mailing Address - Country:US
Mailing Address - Phone:607-336-6362
Mailing Address - Fax:
Practice Address - Street 1:11 PELLETT ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1209
Practice Address - Country:US
Practice Address - Phone:607-336-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0111121225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist