Individual
TIFFANY ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1312 LANG DR, SAINT LOUIS, MO 63135-3044
(314) 653-4848
Mailing address
11160 VILLAGE NORTH DR, SAINT LOUIS, MO 63136-6159
(314) 653-4848
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
2011004964
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
X
X
MO
Enumeration date
10/09/2021
Last updated
10/09/2021
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