Provider Demographics
NPI:1326441940
Name:ELLISON, KIMBERLEE JANETTE DESPAIN (PT, DPT, C/NDT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:JANETTE DESPAIN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PT, DPT, C/NDT
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:JANETTE DESPAIN
Other - Last Name:ODLAUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2302 N 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-1201
Mailing Address - Country:US
Mailing Address - Phone:623-242-6908
Mailing Address - Fax:
Practice Address - Street 1:2302 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-1201
Practice Address - Country:US
Practice Address - Phone:623-242-6908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-28
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60439302225100000X, 2251P0200X
AZLPT-306382251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist