Provider Demographics
NPI:1508825068
Name:PONG, ELLEN JOY (DPT, MOTR/L, CCE)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:JOY
Last Name:PONG
Suffix:
Gender:F
Credentials:DPT, MOTR/L, CCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5147 GARDENBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-2331
Mailing Address - Country:US
Mailing Address - Phone:850-983-6147
Mailing Address - Fax:850-983-8973
Practice Address - Street 1:5147 GARDENBROOK BLVD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2331
Practice Address - Country:US
Practice Address - Phone:850-983-6147
Practice Address - Fax:850-983-8973
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20974225100000X
FL11232225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist