Provider Demographics
NPI:1477957801
Name:ELLIS, BENJAMIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1732
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:ME
Mailing Address - Zip Code:04217-1732
Mailing Address - Country:US
Mailing Address - Phone:207-776-3694
Mailing Address - Fax:
Practice Address - Street 1:420 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2104
Practice Address - Country:US
Practice Address - Phone:207-369-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist