Provider Demographics
NPI:1043035769
Name:HAGADORN, ELLIS AUBREY (DPT)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:AUBREY
Last Name:HAGADORN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S 3RD ST APT 30
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4642
Mailing Address - Country:US
Mailing Address - Phone:949-705-8870
Mailing Address - Fax:
Practice Address - Street 1:142 PROSPECT PARK W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4506
Practice Address - Country:US
Practice Address - Phone:929-560-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist