Provider Demographics
NPI:1699744912
Name:PRYOR, ELLEN (OTRL)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:PRYOR
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241769
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1769
Mailing Address - Country:US
Mailing Address - Phone:907-770-2380
Mailing Address - Fax:907-770-2341
Practice Address - Street 1:4325 LAUREL ST
Practice Address - Street 2:STE 100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5364
Practice Address - Country:US
Practice Address - Phone:907-561-3768
Practice Address - Fax:907-561-3768
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK326225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT0463Medicaid