Provider Demographics
NPI:1215271234
Name:ELLISON, MARK T (DC PT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:ELLISON
Suffix:
Gender:M
Credentials:DC PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 LAKELAND CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1205
Mailing Address - Country:US
Mailing Address - Phone:317-418-0285
Mailing Address - Fax:
Practice Address - Street 1:761 LAKELAND CT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1205
Practice Address - Country:US
Practice Address - Phone:317-418-0285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001711A111N00000X
IN05005146A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist