Provider Demographics
NPI:1093062317
Name:ELLIS, CLAYTON KYLE (PTA)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:KYLE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 ACTON DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4306
Mailing Address - Country:US
Mailing Address - Phone:229-310-0318
Mailing Address - Fax:
Practice Address - Street 1:6 E OAK ST
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-4337
Practice Address - Country:US
Practice Address - Phone:229-868-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant