Provider Demographics
NPI:1760830038
Name:ELLIS, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 WEST CALHOUN
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753
Mailing Address - Country:US
Mailing Address - Phone:870-234-1597
Mailing Address - Fax:
Practice Address - Street 1:301 WEST CALHOUN
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:ARKANSAS
Practice Address - Zip Code:71753
Practice Address - Country:WF
Practice Address - Phone:877-234-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist