Provider Demographics
NPI:1124383310
Name:ELLIS, MARSHA M (BA)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:MARSHA
Other - Middle Name:M
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 W MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3090
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:541-440-3554
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator