Provider Demographics
NPI:1447877246
Name:ELLIS, TARYN MARIE (ATC)
Entity type:Individual
Prefix:
First Name:TARYN
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16323 CHATMAN DR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44149-9049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16761 SOUTHPARK CTR
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-9302
Practice Address - Country:US
Practice Address - Phone:440-878-3382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20000320162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer