Provider Demographics
NPI:1114388303
Name:ELLIS, TIMOTHY (ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1212
Mailing Address - Country:US
Mailing Address - Phone:402-375-7937
Mailing Address - Fax:402-375-7956
Practice Address - Street 1:1200 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1212
Practice Address - Country:US
Practice Address - Phone:402-375-7937
Practice Address - Fax:402-375-7956
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer