Provider Demographics
NPI:1477716843
Name:ELLIS, LEAH (DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4400
Mailing Address - Country:US
Mailing Address - Phone:254-699-3933
Mailing Address - Fax:254-526-8604
Practice Address - Street 1:3816 S CLEAR CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4400
Practice Address - Country:US
Practice Address - Phone:254-699-3933
Practice Address - Fax:254-526-8604
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1179616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist