Provider Demographics
NPI:1477834026
Name:ELLIS, KAROLYN G (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KAROLYN
Middle Name:G
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4906
Mailing Address - Country:US
Mailing Address - Phone:719-345-4097
Mailing Address - Fax:
Practice Address - Street 1:722 S 8TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4906
Practice Address - Country:US
Practice Address - Phone:719-345-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1502171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1502OtherSTATE OF COLORADO