Provider Demographics
NPI:1154500940
Name:LEE, ELLEN (RPT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-3641
Mailing Address - Country:US
Mailing Address - Phone:918-968-2656
Mailing Address - Fax:918-968-2659
Practice Address - Street 1:320 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-3641
Practice Address - Country:US
Practice Address - Phone:918-968-2656
Practice Address - Fax:918-968-2659
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist