Provider Demographics
NPI:1255622627
Name:ELLIS, LISA SUSAN (OT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SUSAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 BRIAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-1203
Mailing Address - Country:US
Mailing Address - Phone:610-645-0178
Mailing Address - Fax:
Practice Address - Street 1:1552 BRIAR HILL RD
Practice Address - Street 2:
Practice Address - City:GLADWYNE
Practice Address - State:PA
Practice Address - Zip Code:19035-1203
Practice Address - Country:US
Practice Address - Phone:610-645-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC-001320L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist