Provider Demographics
NPI:1679805360
Name:ELLIS, LINDA (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 SAMANTHA DR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-4103
Mailing Address - Country:US
Mailing Address - Phone:704-960-9563
Mailing Address - Fax:
Practice Address - Street 1:2034 SAMANTHA DR
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-4103
Practice Address - Country:US
Practice Address - Phone:704-960-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1745224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant