Provider Demographics
NPI:1528204377
Name:ELLISON, EUSTACIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:EUSTACIA
Middle Name:
Last Name:ELLISON
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 1:33-57 HARRISON ST
Mailing Address - Street 2:PICCIANO 3
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2107
Mailing Address - Country:US
Mailing Address - Phone:607-763-5200
Mailing Address - Fax:
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:PICCIANO 3
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility