Provider Demographics
NPI:1245542141
Name:ELLIS DUCK, LARISSA J (OT)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:J
Last Name:ELLIS DUCK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:J
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:1901 N AMBURN RD
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2488
Practice Address - Country:US
Practice Address - Phone:409-933-1687
Practice Address - Fax:409-933-1687
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110377225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist