Provider Demographics
NPI:1629358387
Name:ELLIS, KEISHA (PT)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 TURKEY RUN RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-4929
Mailing Address - Country:US
Mailing Address - Phone:270-463-6173
Mailing Address - Fax:270-465-0068
Practice Address - Street 1:105 LAURA SUE HUMPHRESS DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8899
Practice Address - Country:US
Practice Address - Phone:270-465-7768
Practice Address - Fax:270-465-0068
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist