Healthcare Provider Details

I. General information

NPI: 1497676753
Provider Name (Legal Business Name): MARLON ELLERBEE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12216 HILLANTRAE DR
CLINTON MD
20735-4522
US

IV. Provider business mailing address

12216 HILLANTRAE DR
CLINTON MD
20735-4522
US

V. Phone/Fax

Practice location:
  • Phone: 202-486-1597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: