Provider Demographics
NPI:1750656583
Name:ELLIS, LINDA A (BA, LMT)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 EASY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-4726
Mailing Address - Country:US
Mailing Address - Phone:478-719-2424
Mailing Address - Fax:
Practice Address - Street 1:2484 INGLESIDE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2089
Practice Address - Country:US
Practice Address - Phone:478-719-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT 000308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist