Provider Demographics
NPI:1215283502
Name:ELLENBERGER, JULIE ANN (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:JULIE
Middle Name:ANN
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:425-313-3055
Mailing Address - Fax:425-313-3051
Practice Address - Street 1:510 8TH AVE NE STE 340
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5449
Practice Address - Country:US
Practice Address - Phone:425-313-3055
Practice Address - Fax:425-313-3051
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60302480225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2105652Medicaid