Provider Demographics
NPI:1912128760
Name:ELLIS, BRIAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 DAR LIND LANE
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522
Mailing Address - Country:US
Mailing Address - Phone:704-315-7734
Mailing Address - Fax:
Practice Address - Street 1:1809 BRENNER AVE STE 102
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2567
Practice Address - Country:US
Practice Address - Phone:704-637-6057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC54322251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic