Provider Demographics
NPI:1578189270
Name:WALL, ELLIS B
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:B
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13545 KINTYRE CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-3032
Mailing Address - Country:US
Mailing Address - Phone:919-449-7954
Mailing Address - Fax:
Practice Address - Street 1:136 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6959
Practice Address - Country:US
Practice Address - Phone:919-449-7954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist