Provider Demographics
NPI:1700968864
Name:ELLISON, MICHELLE C (P T)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:C
Last Name:ELLISON
Suffix:
Gender:F
Credentials:P T
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:C
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2416 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1320
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:276 NISSAN PKWY
Practice Address - Street 2:SUITE 400, BLDG F
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-7006
Practice Address - Country:US
Practice Address - Phone:601-859-3776
Practice Address - Fax:601-859-3778
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS PT0747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5965404OtherAETNA
MS650000259Medicare ID - Type Unspecified