MEDICARE: DENISE W ELLISON

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	103K00000X	Behavior Analyst	2084	CT
2	106S00000X	Behavior Technician		CT

General Provider Information

NPI Number	:	1639751753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE W ELLISON

Provider Business Mailing Address
First Line	:	15 PAPINEAU ST
Second Line	:
City	:	HOLYOKE
State	:	MA
Zip	:	01040-3417
Country	:	US
Telephone Number	:	413-262-3721
Fax Number	:	413-507-3363

Provider Business Practice Location Address
First Line	:	15 PAPINEAU ST
Second Line	:
City	:	HOLYOKE
State	:	MA
Zip	:	01040-3417
Country	:	US
Telephone Number	:	413-262-3721
Fax Number	:

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

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	03/25/2025

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