Provider Demographics
NPI:1104011949
Name:ELLIS, JUDITH ANN (LPT)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 FOUNTAIN PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8031
Mailing Address - Country:US
Mailing Address - Phone:956-316-2224
Mailing Address - Fax:956-316-0445
Practice Address - Street 1:1403 N. SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-8752
Practice Address - Country:US
Practice Address - Phone:956-683-1155
Practice Address - Fax:956-683-1188
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1075695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist