Provider Demographics
NPI:1881186575
Name:ELLISON, AMANDA REBECCA (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:REBECCA
Last Name:ELLISON
Suffix:
Gender:F
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:PO BOX 22184
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-0184
Mailing Address - Country:US
Mailing Address - Phone:502-425-1716
Mailing Address - Fax:502-425-2258
Practice Address - Street 1:10321 CHAMPION FARMS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6129
Practice Address - Country:US
Practice Address - Phone:502-425-1716
Practice Address - Fax:502-425-2258
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist