Provider Demographics
NPI:1952654436
Name:ELLIS, CLARA NANETTE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:NANETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 BOSKYDELL RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7714
Mailing Address - Country:US
Mailing Address - Phone:618-457-7832
Mailing Address - Fax:
Practice Address - Street 1:801 E REEVES ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-3366
Practice Address - Country:US
Practice Address - Phone:618-534-2432
Practice Address - Fax:618-993-1615
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist