Provider Demographics
NPI:1871253286
Name:ELLIS, BROOKE JULIETTE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:JULIETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 OAKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-2717
Mailing Address - Country:US
Mailing Address - Phone:860-593-2364
Mailing Address - Fax:
Practice Address - Street 1:113 ELM ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3700
Practice Address - Country:US
Practice Address - Phone:860-253-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-27
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14292225XH1200X
CT5940225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand