Provider Demographics
NPI:1497841167
Name:ELLIS, CHRISTOPHER RAY (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RAY
Last Name:ELLIS
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:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0136
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:1838 W PARKSIDE LN STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1370
Practice Address - Country:US
Practice Address - Phone:480-454-4698
Practice Address - Fax:480-454-4699
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9914225100000X
AZ7409225100000X
AZ11359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ153812Medicaid
AZ153812Medicaid
CO24820571Medicaid