Provider Demographics
NPI:1730720913
Name:ELLIS, MICHELE (MED, OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MED, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PENNTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-8815
Mailing Address - Country:US
Mailing Address - Phone:724-787-0582
Mailing Address - Fax:
Practice Address - Street 1:555 RIAL LN
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-4683
Practice Address - Country:US
Practice Address - Phone:724-834-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
PAOC-000166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist