Provider Demographics
NPI:1528288511
Name:BEALS, ELLEN WEYBRIGHT (OTR)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:WEYBRIGHT
Last Name:BEALS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:ELLEN
Other - Last Name:WEYBRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 11471
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-0471
Mailing Address - Country:US
Mailing Address - Phone:518-877-4970
Mailing Address - Fax:866-415-1258
Practice Address - Street 1:626 WATERVLIET SHAKER RD
Practice Address - Street 2:SUITE 71
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-3618
Practice Address - Country:US
Practice Address - Phone:518-877-4970
Practice Address - Fax:866-415-1258
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007564225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02871630Medicaid
NY007564OtherNYS LICENSE NUMBER
NY02871630Medicaid
NY007564OtherNYS LICENSE NUMBER