Provider Demographics
NPI:1578572079
Name:DECOTIIS, ELLEN H (MSLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:H
Last Name:DECOTIIS
Suffix:
Gender:F
Credentials:MSLP
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 608
Mailing Address - Street 2:
Mailing Address - City:BAR MILLS
Mailing Address - State:ME
Mailing Address - Zip Code:04004-0608
Mailing Address - Country:US
Mailing Address - Phone:207-929-4104
Mailing Address - Fax:
Practice Address - Street 1:78 DEPOT ST
Practice Address - Street 2:
Practice Address - City:BAR MILLS
Practice Address - State:ME
Practice Address - Zip Code:04004
Practice Address - Country:US
Practice Address - Phone:207-809-9496
Practice Address - Fax:207-839-2197
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME224340000Medicaid
ME001035OtherANTHEM BLUE CROSS