MEDICARE: JOHN DARRIS ELLIS PMFT

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	106H00000X	Marriage & Family Therapist	PMFT-255	WY

General Provider Information

NPI Number	:	1750637393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN DARRIS ELLIS PMFT

Provider Business Mailing Address
First Line	:	672 W 400 S STE 201
Second Line	:
City	:	SPRINGVILLE
State	:	UT
Zip	:	84663-3170
Country	:	US
Telephone Number	:	801-369-8989
Fax Number	:	307-527-6218

Provider Business Practice Location Address
First Line	:	721 EAST 12200 SOUTH
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84040-8404
Country	:	US
Telephone Number	:	801-369-8989
Fax Number	:	801-704-9741

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

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	02/02/2021

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