Provider Demographics
NPI:1235803826
Name:ELLIS, KORI LYNN (OTR)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:LYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BERKLEY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1329
Mailing Address - Country:US
Mailing Address - Phone:804-365-4500
Mailing Address - Fax:
Practice Address - Street 1:8290 NEW ASHCAKE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-4033
Practice Address - Country:US
Practice Address - Phone:804-723-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008543225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist