Provider Demographics
NPI:1871067975
Name:ELLIS, KENDRA ANN (MASTER OF SCIENCE)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MASTER OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 MIDDLEHOFF LN APT D
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95965-4448
Mailing Address - Country:US
Mailing Address - Phone:831-295-1216
Mailing Address - Fax:
Practice Address - Street 1:725 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5655
Practice Address - Country:US
Practice Address - Phone:530-749-7529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist