Provider Demographics
NPI:1710328729
Name:ELLINGSON, TAYLOR LEIGH (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEIGH
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEIGH
Other - Last Name:KADLEC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:1661 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3733
Practice Address - Country:US
Practice Address - Phone:651-968-5335
Practice Address - Fax:651-730-3989
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist