Provider Demographics
NPI:1013492230
Name:MASON, ELLISSA LAUREN (PTA)
Entity type:Individual
Prefix:MS
First Name:ELLISSA
Middle Name:LAUREN
Last Name:MASON
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 1:133 HIGHWAY 321
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9726
Mailing Address - Country:US
Mailing Address - Phone:501-203-7966
Mailing Address - Fax:
Practice Address - Street 1:3131 TOM AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-4801
Practice Address - Country:US
Practice Address - Phone:615-382-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4350225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4350OtherPHYSICAL THERAPIST ASSISTANT