Provider Demographics
NPI:1164849980
Name:COUSINEAU, ELLEN (OTR/L)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:PATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1023 VALERIE CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5054
Mailing Address - Country:US
Mailing Address - Phone:505-603-5032
Mailing Address - Fax:
Practice Address - Street 1:826 CAMINO DEL MONTE REY
Practice Address - Street 2:SUITE A2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3977
Practice Address - Country:US
Practice Address - Phone:505-954-9940
Practice Address - Fax:505-954-9946
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3189225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist