Provider Demographics
NPI:1750637393
Name:ELLIS, JOHN DARRIS (PMFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DARRIS
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 W 400 S STE 201
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3170
Mailing Address - Country:US
Mailing Address - Phone:801-369-8989
Mailing Address - Fax:307-527-6218
Practice Address - Street 1:721 EAST 12200 SOUTH
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84040-8404
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPMFT-255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist