Provider Demographics
NPI:1205364387
Name:ELLIS, CYNTHIA (PTA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:ELLIS
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 1:76 KIRK AND FITTS RD
Mailing Address - Street 2:
Mailing Address - City:ALBURGH
Mailing Address - State:VT
Mailing Address - Zip Code:05440-4412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 FAIRFAX RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-6299
Practice Address - Country:US
Practice Address - Phone:802-752-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0410069437225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant