Provider Demographics
NPI:1679602197
Name:ELLISON, MALLIE
Entity Type:Individual
Prefix:MRS
First Name:MALLIE
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GOODYEAR AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1195
Mailing Address - Country:US
Mailing Address - Phone:256-538-2273
Mailing Address - Fax:256-538-9373
Practice Address - Street 1:425 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:ATTALLA
Practice Address - State:AL
Practice Address - Zip Code:35954-2214
Practice Address - Country:US
Practice Address - Phone:256-538-2273
Practice Address - Fax:256-538-9373
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist