Provider Demographics
NPI:1396925848
Name:ELLIS, BETHANY ANNE (BS)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 CAMBRIDGE ST
Mailing Address - Street 2:APT #4
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1361
Mailing Address - Country:US
Mailing Address - Phone:978-772-1274
Mailing Address - Fax:
Practice Address - Street 1:100 ERDMAN WAY
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1804
Practice Address - Country:US
Practice Address - Phone:978-840-9354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA392110222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist