Provider Demographics
NPI:1326116971
Name:ELLIS, CYNTHIA A (PT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
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 11400
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29211-1400
Mailing Address - Country:US
Mailing Address - Phone:803-783-0684
Mailing Address - Fax:803-783-1147
Practice Address - Street 1:6041B GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1304
Practice Address - Country:US
Practice Address - Phone:803-783-0684
Practice Address - Fax:803-783-1147
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist