Provider Demographics
NPI:1154741692
Name:ELLIS, ERIC DANIEL (MS, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DANIEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4311
Mailing Address - Country:US
Mailing Address - Phone:484-680-6341
Mailing Address - Fax:610-359-1686
Practice Address - Street 1:414 BRYAN ST
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4311
Practice Address - Country:US
Practice Address - Phone:484-680-6341
Practice Address - Fax:610-359-1686
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0042882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer