Provider Demographics
NPI:1770254484
Name:ELLINGWOOD, CATHY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:ANN
Last Name:ELLINGWOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8802 W 400 S
Mailing Address - Street 2:
Mailing Address - City:WAYNETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47990-8196
Mailing Address - Country:US
Mailing Address - Phone:765-376-8534
Mailing Address - Fax:
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-502-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000850A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant