Provider Demographics
NPI:1104125814
Name:DISLER, ELLEN (COTA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DISLER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1586 PREIDT CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-7589
Mailing Address - Country:US
Mailing Address - Phone:248-488-0350
Mailing Address - Fax:
Practice Address - Street 1:27240 HAGGERTY RD # 15
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5716
Practice Address - Country:US
Practice Address - Phone:248-488-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001539A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant