Provider Demographics
NPI:1639507312
Name:ELLI, EVELYN (PT)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:ELLI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 TARGEE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4518
Mailing Address - Country:US
Mailing Address - Phone:718-524-7509
Mailing Address - Fax:
Practice Address - Street 1:879 TARGEE ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4518
Practice Address - Country:US
Practice Address - Phone:718-524-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist