Provider Demographics
NPI:1679859094
Name:ELLIS, NATHAN (OTR)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13664-3219
Mailing Address - Country:US
Mailing Address - Phone:315-375-6383
Mailing Address - Fax:
Practice Address - Street 1:139 OUTER STATE ST. RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-386-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010670-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics