Provider Demographics
NPI:1427698927
Name:ELLISON, MARY CLARINE (OTD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:CLARINE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 AGATE CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-8226
Mailing Address - Country:US
Mailing Address - Phone:970-227-6496
Mailing Address - Fax:
Practice Address - Street 1:3128 BOXELDER DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5808
Practice Address - Country:US
Practice Address - Phone:307-634-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1472225X00000X
COOT-6066225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist