Provider Demographics
NPI:1386845071
Name:ELLIS, MARQUIS R (OTR-L)
Entity Type:Individual
Prefix:
First Name:MARQUIS
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-4311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5406 MERLE HAY RD
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1209
Practice Address - Country:US
Practice Address - Phone:515-727-8750
Practice Address - Fax:515-727-8757
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000905225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29818OtherWELLMARK BCBS