Provider Demographics
NPI:1518206580
Name:BASS, ELLEN JOY (DPT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JOY
Last Name:BASS
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 1:319 W TOWN PL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3101
Mailing Address - Country:US
Mailing Address - Phone:904-342-5262
Mailing Address - Fax:904-217-3580
Practice Address - Street 1:319 W TOWN PL
Practice Address - Street 2:SUITE 5
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3101
Practice Address - Country:US
Practice Address - Phone:904-342-5262
Practice Address - Fax:904-217-3580
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist