Basic Information
| Provider Information | |||||||||
| NPI: | 1578572079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECOTIIS | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.S.L.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 608 | ||||||||
| Address2: | |||||||||
| City: | BAR MILLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040040608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079294104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 78 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | BAR MILLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078099496 | ||||||||
| FaxNumber: | 2078392197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP439 | ME | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 224340000 | 05 | ME | MEDICAID | 001035 | 01 | ME | ANTHEM BLUE CROSS | OTHER |