Provider Demographics
NPI:1760893705
Name:ELLIS, DANIEL ALEXANDER (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ALEXANDER
Last Name:ELLIS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CLARENDON DR.
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642
Mailing Address - Country:US
Mailing Address - Phone:864-423-2446
Mailing Address - Fax:
Practice Address - Street 1:801 N. HAMILTON ST.
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697
Practice Address - Country:US
Practice Address - Phone:864-847-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2684224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant