Healthcare Provider Details

I. General information

NPI: 1407334998
Provider Name (Legal Business Name): BRETT ELLIS MARTIN M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 S COUNTRY CLUB DR STE 20
MESA AZ
85210-6879
US

IV. Provider business mailing address

PO BOX 50218
PHOENIX AZ
85076-0218
US

V. Phone/Fax

Practice location:
  • Phone: 480-398-4280
  • Fax: 480-398-4281
Mailing address:
  • Phone: 480-398-4280
  • Fax: 480-398-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: