Provider Demographics
NPI:1033425806
Name:ELLIS, BETHANY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ANN
Last Name:ELLIS
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 1:5545 HIGHWAY 145
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:MS
Mailing Address - Zip Code:38868-9351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5545 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SHANNON
Practice Address - State:MS
Practice Address - Zip Code:38868-9351
Practice Address - Country:US
Practice Address - Phone:662-871-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3896174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist