Provider Demographics
NPI:1003403908
Name:MICHAEL, ELLIE VICTORIA (PTA)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:VICTORIA
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 CAROLINA OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-8506
Mailing Address - Country:US
Mailing Address - Phone:864-612-0727
Mailing Address - Fax:
Practice Address - Street 1:1305 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4139
Practice Address - Country:US
Practice Address - Phone:864-458-7566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4556225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant