Provider Demographics
NPI:1710296918
Name:VAN WERT, ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:VAN WERT
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 1:465 WAVERLY OAKS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 WAVERLY OAKS RD STE 101
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8497
Practice Address - Country:US
Practice Address - Phone:781-325-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7018120Medicaid