Provider Demographics
NPI:1316412851
Name:ELLIS, CANDACE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BRIGHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12833-1849
Mailing Address - Country:US
Mailing Address - Phone:518-729-7047
Mailing Address - Fax:
Practice Address - Street 1:210 BRIGHAM RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD CENTER
Practice Address - State:NY
Practice Address - Zip Code:12833-1849
Practice Address - Country:US
Practice Address - Phone:518-729-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist