Provider Demographics
NPI:1487063582
Name:RUSYNIAK, ELLEN
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:RUSYNIAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7349 FAIR HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-8710
Mailing Address - Country:US
Mailing Address - Phone:315-399-9399
Mailing Address - Fax:
Practice Address - Street 1:2130 WEBBER RD
Practice Address - Street 2:
Practice Address - City:NEW WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:13122-9729
Practice Address - Country:US
Practice Address - Phone:315-662-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006378-1225X00000X, 225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist