Provider Demographics
NPI:1093264269
Name:ELLIS, KOURTNEY KOBER (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KOURTNEY
Middle Name:KOBER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 NELSON RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2439
Mailing Address - Country:US
Mailing Address - Phone:337-494-7546
Mailing Address - Fax:337-494-7548
Practice Address - Street 1:4080 NELSON RD
Practice Address - Street 2:SUITE 500
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2439
Practice Address - Country:US
Practice Address - Phone:337-494-7546
Practice Address - Fax:337-494-7548
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist