Provider Demographics
NPI:1790078277
Name:DECOSTER, ELLEN (OTR)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DECOSTER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FOREST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3041
Mailing Address - Country:US
Mailing Address - Phone:207-210-4569
Mailing Address - Fax:
Practice Address - Street 1:136 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-2406
Practice Address - Country:US
Practice Address - Phone:978-443-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10125225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist