Healthcare Provider Details

I. General information

NPI: 1184359879
Provider Name (Legal Business Name): PETER MARK ANTHONY ELLISON JR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT # 3B
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

PO BOX 866308
PLANO TX
75086-6308
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-3790
  • Fax: 203-265-2120
Mailing address:
  • Phone: 347-310-8857
  • Fax: 717-635-4785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14200
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: