Provider Demographics
NPI:1689812083
Name:ELLIS, CHERYL LEIGH (ATC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LEIGH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 DANTIGNAC ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2774
Mailing Address - Country:US
Mailing Address - Phone:706-823-3807
Mailing Address - Fax:706-823-3810
Practice Address - Street 1:1305 DANTIGNAC ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2774
Practice Address - Country:US
Practice Address - Phone:706-823-3807
Practice Address - Fax:706-823-3810
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0008542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer