MEDICARE: ELLIE ROSE COHEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	CB70056809	WA

General Provider Information

NPI Number	:	1255208203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIE ROSE COHEN

Provider Business Mailing Address
First Line	:	3231 WILLAMETTE DR NE STE A
Second Line	:
City	:	LACEY
State	:	WA
Zip	:	98516-1378
Country	:	US
Telephone Number	:	360-878-6434
Fax Number	:	844-452-1758

Provider Business Practice Location Address
First Line	:	2584 R W JOHNSON BLVD SW STE 100
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98512-6103
Country	:	US
Telephone Number	:	360-878-6434
Fax Number	:	844-452-1758

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	10/22/2025

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Directions to “ ELLIE ROSE COHEN ” Practice Location

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