Basic Information
| Provider Information | |||||||||
| NPI: | 1902491434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6590 TRYON RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198518000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6590 TRYON RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198518000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.