Provider Demographics
NPI:1912014754
Name:ELLIS, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 W HORIZON RIDGE PKWY STE 121
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5016
Mailing Address - Country:US
Mailing Address - Phone:702-897-7331
Mailing Address - Fax:702-897-6801
Practice Address - Street 1:2904 W HORIZON RIDGE PKWY STE 121
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5016
Practice Address - Country:US
Practice Address - Phone:702-897-7331
Practice Address - Fax:702-897-6801
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NV2517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2001017939OtherLICENSE #