Provider Demographics
NPI:1124400486
Name:ELLISON, SARAH (PTA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:ELLISON
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 1:100 LOCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6664
Mailing Address - Country:US
Mailing Address - Phone:405-618-8638
Mailing Address - Fax:
Practice Address - Street 1:1300 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5304
Practice Address - Country:US
Practice Address - Phone:405-422-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2483225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant