Provider Demographics
NPI:1205502317
Name:ELLIS, JOELLE KAELYNN (LMT)
Entity type:Individual
Prefix:
First Name:JOELLE
Middle Name:KAELYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10926 SW CELESTE LN APT 406
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-7111
Mailing Address - Country:US
Mailing Address - Phone:541-654-6984
Mailing Address - Fax:
Practice Address - Street 1:5035 NE ELAM YOUNG PKWY STE 500
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6473
Practice Address - Country:US
Practice Address - Phone:503-844-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty