Provider Demographics
NPI:1346850021
Name:BOOTHE, ELLISA
Entity Type:Individual
Prefix:
First Name:ELLISA
Middle Name:
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 W PLEASURE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-5151
Mailing Address - Country:US
Mailing Address - Phone:501-368-0447
Mailing Address - Fax:
Practice Address - Street 1:1208 W PLEASURE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5151
Practice Address - Country:US
Practice Address - Phone:501-368-0447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty