Basic Information
| Provider Information | |||||||||
| NPI: | 1245542141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS DUCK | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | LARISSA | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2222 SULLIVAN TRL | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180407958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009449782 | ||||||||
| FaxNumber: | 6104382046 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 N AMBURN RD | ||||||||
| Address2: | |||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775912488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099331687 | ||||||||
| FaxNumber: | 4099331687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 110377 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.