Provider Demographics
NPI:1659156461
Name:CYR, ELLISSA ANDREEN (BA)
Entity Type:Individual
Prefix:MS
First Name:ELLISSA
Middle Name:ANDREEN
Last Name:CYR
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 1/2 COURT AVENUE
Mailing Address - Street 2:BOX 1027
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255-1027
Mailing Address - Country:US
Mailing Address - Phone:406-768-3852
Mailing Address - Fax:406-768-5202
Practice Address - Street 1:127 E FRONT ST
Practice Address - Street 2:
Practice Address - City:WOLF POINT
Practice Address - State:MT
Practice Address - Zip Code:59201-1402
Practice Address - Country:US
Practice Address - Phone:406-653-6001
Practice Address - Fax:406-653-2764
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-50261390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty