Provider Demographics
NPI:1558007641
Name:MUNDIE-OTT, ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MUNDIE-OTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:MUNDIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:9660 BARTLETT CIR # 708
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4465
Mailing Address - Country:US
Mailing Address - Phone:817-862-9665
Mailing Address - Fax:817-862-9667
Practice Address - Street 1:9660 BARTLETT CIR STE 708
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-4465
Practice Address - Country:US
Practice Address - Phone:817-862-9665
Practice Address - Fax:817-862-9667
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1360228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist