Provider Demographics
NPI:1730757071
Name:PARK, ELLENNE J (PT, DPT, CSRS)
Entity type:Individual
Prefix:
First Name:ELLENNE
Middle Name:J
Last Name:PARK
Suffix:
Gender:F
Credentials:PT, DPT, CSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 PACIFIC AVE APT 24
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-1959
Mailing Address - Country:US
Mailing Address - Phone:908-331-4931
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist