Healthcare Provider Details

I. General information

NPI: 1063068476
Provider Name (Legal Business Name): MORGAN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N JEFFERSON ST
ROANOKE VA
24016-1427
US

IV. Provider business mailing address

611 S JEFFERSON ST APT 159
ROANOKE VA
24011-2439
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-5111
  • Fax:
Mailing address:
  • Phone: 540-845-9885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119008246
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: