Provider Demographics
NPI:1922233246
Name:ELLIS, KELLY ABBOTT (DPT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ABBOTT
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:NOELLE
Other - Last Name:ABBOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4953 MACAW CT NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-1286
Mailing Address - Country:US
Mailing Address - Phone:770-714-0958
Mailing Address - Fax:
Practice Address - Street 1:4953 MACAW CT NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-1286
Practice Address - Country:US
Practice Address - Phone:770-714-0958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-17
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist