Healthcare Provider Details

I. General information

NPI: 1750243523
Provider Name (Legal Business Name): ELLIE GRACE CAPPUCIO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 FRANKLIN ST
LYNN MA
01904-3230
US

IV. Provider business mailing address

44 BRIDLE PATH RD
LYNN MA
01904-1261
US

V. Phone/Fax

Practice location:
  • Phone: 781-593-2727
  • Fax:
Mailing address:
  • Phone: 617-852-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: