Provider Demographics
NPI:1487969168
Name:ELLIS, CRYSTAL R (OT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CASTOR CV
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225-9301
Mailing Address - Country:US
Mailing Address - Phone:318-644-2797
Mailing Address - Fax:
Practice Address - Street 1:1828 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4938
Practice Address - Country:US
Practice Address - Phone:318-338-2081
Practice Address - Fax:318-699-8954
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12381174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist