Provider Demographics
NPI:1578341442
Name:FELLERS, LAURA ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:FELLERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14176 NATIONAL RD SW
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:OH
Mailing Address - Zip Code:43068-3363
Mailing Address - Country:US
Mailing Address - Phone:740-927-6782
Mailing Address - Fax:740-927-9018
Practice Address - Street 1:14176 NATIONAL RD SW
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:OH
Practice Address - Zip Code:43068-3363
Practice Address - Country:US
Practice Address - Phone:740-927-6782
Practice Address - Fax:740-927-9018
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OHPTA009163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty