Provider Demographics
NPI:1629088646
Name:CRAIG, ELLEN ROE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:ROE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 BUCKBOARD RD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9431
Mailing Address - Country:US
Mailing Address - Phone:916-663-3573
Mailing Address - Fax:
Practice Address - Street 1:2945 BELL ROAD
Practice Address - Street 2:#215
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603
Practice Address - Country:US
Practice Address - Phone:916-367-1888
Practice Address - Fax:530-888-0885
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OPT16260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ08443ZOtherBLUE SHIELD
ZZZ08443ZOtherBLUE SHIELD