Provider Demographics
NPI:1003154568
Name:ELLINGFORD, CHRISTY JEAN (CMT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:JEAN
Last Name:ELLINGFORD
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MS
Other - First Name:CHRISTY
Other - Middle Name:JEAN
Other - Last Name:FRERICHS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMT
Mailing Address - Street 1:671 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5596
Mailing Address - Country:US
Mailing Address - Phone:208-552-2584
Mailing Address - Fax:208-529-3992
Practice Address - Street 1:671 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5596
Practice Address - Country:US
Practice Address - Phone:208-552-2584
Practice Address - Fax:208-529-3992
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist