Provider Demographics
NPI:1659681476
Name:ELLISON, TERESA RUTH (LMT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:RUTH
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-0483
Mailing Address - Country:US
Mailing Address - Phone:606-215-0977
Mailing Address - Fax:606-549-4814
Practice Address - Street 1:412 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1137
Practice Address - Country:US
Practice Address - Phone:606-215-0977
Practice Address - Fax:606-549-4814
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY2650225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist