Provider Demographics
NPI:1750664967
Name:ELLIS, ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 ATWOOD DRIVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-623-2057
Mailing Address - Fax:
Practice Address - Street 1:5006 ATWOOD DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-623-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist