Provider Demographics
NPI:1801877196
Name:ELLIS, MARCIA K (PT)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:K
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3850
Mailing Address - Country:US
Mailing Address - Phone:520-408-9547
Mailing Address - Fax:520-293-6638
Practice Address - Street 1:5501 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3829
Practice Address - Country:US
Practice Address - Phone:520-408-9547
Practice Address - Fax:520-293-6638
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ78503Medicare ID - Type Unspecified