Provider Demographics
NPI:1790017630
Name:WHEALTON, ELLEN (MT-BC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WHEALTON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 TEHAMA CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5425
Mailing Address - Country:US
Mailing Address - Phone:512-402-0977
Mailing Address - Fax:
Practice Address - Street 1:3221 TEHAMA CT
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5425
Practice Address - Country:US
Practice Address - Phone:512-402-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09176225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist