Provider Demographics
NPI:1639941073
Name:WILLIAMS, ELLIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40110 N PREAKNESS CT
Mailing Address - Street 2:
Mailing Address - City:AGUANGA
Mailing Address - State:CA
Mailing Address - Zip Code:92536-9312
Mailing Address - Country:US
Mailing Address - Phone:951-847-6780
Mailing Address - Fax:
Practice Address - Street 1:40110 N PREAKNESS CT
Practice Address - Street 2:
Practice Address - City:AGUANGA
Practice Address - State:CA
Practice Address - Zip Code:92536-9312
Practice Address - Country:US
Practice Address - Phone:951-847-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA6233224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant