Provider Demographics
NPI:1164623153
Name:ELLERY, MARYANN MAUDE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:MAUDE
Last Name:ELLERY
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:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:MI
Mailing Address - Zip Code:48633-0412
Mailing Address - Country:US
Mailing Address - Phone:989-539-4937
Mailing Address - Fax:
Practice Address - Street 1:805 WEST AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9274
Practice Address - Country:US
Practice Address - Phone:231-796-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant