Provider Demographics
NPI:1821657313
Name:ELLIS, SEAN (DPT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 PINEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7123
Mailing Address - Country:US
Mailing Address - Phone:941-484-8107
Mailing Address - Fax:941-484-5186
Practice Address - Street 1:834 PINEBROOK RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7123
Practice Address - Country:US
Practice Address - Phone:941-484-8107
Practice Address - Fax:941-484-5186
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34736OtherPHYSICAL THERAPIST LICENSE