Provider Demographics
NPI:1447535067
Name:ELLIS, AILEEN HITOMI (COTA/L)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:HITOMI
Last Name:ELLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:HITOMI
Other - Last Name:NISHIMURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:715 E ELK AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1750
Mailing Address - Country:US
Mailing Address - Phone:818-220-1664
Mailing Address - Fax:
Practice Address - Street 1:715 E ELK AVE UNIT C
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1750
Practice Address - Country:US
Practice Address - Phone:818-220-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant