Provider Demographics
NPI:1346557824
Name:COLE-WESSON, ELLEN ELIZABETH (OT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:COLE-WESSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 PARK AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5720
Mailing Address - Country:US
Mailing Address - Phone:731-453-5511
Mailing Address - Fax:731-646-0285
Practice Address - Street 1:705 E POPLAR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1828
Practice Address - Country:US
Practice Address - Phone:731-453-5511
Practice Address - Fax:731-646-0285
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2500225X00000X
TNOT4254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSOT2500OtherBOARD OF OCCUPATIONAL THERAPY
TNOT4254OtherBOARD OF OCCUPATIONAL THERAPY