Provider Demographics
NPI:1093420028
Name:ELLISON, DESIRAE SERENE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:SERENE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 OKEY L PATTESON RD
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-8022
Mailing Address - Country:US
Mailing Address - Phone:304-520-1426
Mailing Address - Fax:681-207-7029
Practice Address - Street 1:21 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3615
Practice Address - Country:US
Practice Address - Phone:304-890-8020
Practice Address - Fax:681-207-7029
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2018-3632225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist