Basic Information
| Provider Information | |||||||||
| NPI: | 1780136879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | LEIGHANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 UNICORN PARK DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018013342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817821300 | ||||||||
| FaxNumber: | 7817821350 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 UNIVERSITY DR | ||||||||
| Address2: | SUITE A-6 | ||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133665703 | ||||||||
| FaxNumber: | 4139922019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 22540 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.