Provider Demographics
NPI:1669663977
Name:ELLORIMO, WWINDELL GO (PT)
Entity Type:Individual
Prefix:MR
First Name:WWINDELL
Middle Name:GO
Last Name:ELLORIMO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 PLUM RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172
Mailing Address - Country:US
Mailing Address - Phone:812-248-9254
Mailing Address - Fax:
Practice Address - Street 1:545 MOONGLO RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170
Practice Address - Country:US
Practice Address - Phone:812-248-9254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007687A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist