Basic Information
| Provider Information | |||||||||
| NPI: | 1972083673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | ALEESA | ||||||||
| MiddleName: | JORDAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORRIS | ||||||||
| OtherFirstName: | ALEESA | ||||||||
| OtherMiddleName: | JORDAN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 YATES ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754573233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035374424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 YATES ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754573233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035374424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 213101 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.