Provider Demographics
NPI:1356050272
Name:LOCKWOOD, ELLERY JAIMES
Entity type:Individual
Prefix:
First Name:ELLERY
Middle Name:JAIMES
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-1948
Mailing Address - Country:US
Mailing Address - Phone:224-789-9696
Mailing Address - Fax:
Practice Address - Street 1:160 W COCHRAN ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6215
Practice Address - Country:US
Practice Address - Phone:805-864-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21955225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist