MEDICARE: LARISSA J ELLIS DUCK OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	110377	TX

General Provider Information

NPI Number	:	1245542141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA J ELLIS DUCK OT

Provider Business Mailing Address
First Line	:	2222 SULLIVAN TRL
Second Line	:
City	:	EASTON
State	:	PA
Zip	:	18040-7958
Country	:	US
Telephone Number	:	800-944-9782
Fax Number	:	610-438-2046

Provider Business Practice Location Address
First Line	:	1901 N AMBURN RD
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77591-2488
Country	:	US
Telephone Number	:	409-933-1687
Fax Number	:	409-933-1687

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2010
Last Update Date	:	07/01/2013

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