Provider Demographics
NPI:1003449984
Name:ELLISON, LILLIAN ELISE
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:ELISE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10133 FINCASTLE WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45697-9495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19189 OH STATE ROUTE 136
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45697
Practice Address - Country:US
Practice Address - Phone:937-695-0839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT015118225100000X
KY006628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist