Provider Demographics
NPI:1831533876
Name:ELLIS, KRISTIN JENNIFER (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:JENNIFER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CLARENDON DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-9334
Mailing Address - Country:US
Mailing Address - Phone:864-607-8696
Mailing Address - Fax:
Practice Address - Street 1:850 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5842
Practice Address - Country:US
Practice Address - Phone:864-527-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2905225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist