Provider Demographics
NPI:1649735515
Name:ELLIS, CAROL (PTA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:MCCLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:804 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3623
Mailing Address - Country:US
Mailing Address - Phone:605-660-6497
Mailing Address - Fax:
Practice Address - Street 1:901 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:SD
Practice Address - Zip Code:57319-2004
Practice Address - Country:US
Practice Address - Phone:605-421-8549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant