Provider Demographics
NPI:1083444723
Name:ELLIS, DOMINIQUE (PT, DPT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1550
Mailing Address - Country:US
Mailing Address - Phone:347-867-2243
Mailing Address - Fax:
Practice Address - Street 1:4620 RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1550
Practice Address - Country:US
Practice Address - Phone:347-867-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049264-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist