Provider Demographics
NPI:1386657799
Name:ELLEXSON, THOMAS LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LEE
Last Name:ELLEXSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6260 SHADY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-7100
Mailing Address - Country:US
Mailing Address - Phone:540-444-0291
Mailing Address - Fax:
Practice Address - Street 1:1620 APPERSON DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7217
Practice Address - Country:US
Practice Address - Phone:540-444-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist