Provider Demographics
NPI:1548481948
Name:ELLENBOGEN, MICHAEL STEPHEN (LPTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:ELLENBOGEN
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 ROCKY FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-8441
Mailing Address - Country:US
Mailing Address - Phone:717-597-8132
Mailing Address - Fax:
Practice Address - Street 1:1335 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-7505
Practice Address - Country:US
Practice Address - Phone:717-263-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE005265L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant