Provider Demographics
NPI:1003069147
Name:ELLIS, MARK BRYAN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:BRYAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 LORENE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-9137
Mailing Address - Country:US
Mailing Address - Phone:501-605-8113
Mailing Address - Fax:
Practice Address - Street 1:9601 INTERSTATE 630 EXIT 7
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7202
Practice Address - Country:US
Practice Address - Phone:501-202-7598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist