Provider Demographics
NPI:1265267793
Name:ELLIS, LATIFIA (LMT)
Entity type:Individual
Prefix:
First Name:LATIFIA
Middle Name:
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 1:10260 PLEASANT LAKE BLVD APT C5
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7463
Mailing Address - Country:US
Mailing Address - Phone:216-329-7770
Mailing Address - Fax:
Practice Address - Street 1:707 BROOKPARK RD # 206C
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-5800
Practice Address - Country:US
Practice Address - Phone:216-329-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist