Provider Demographics
NPI:1720276850
Name:SANDERS, ELLISON RENEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELLISON
Middle Name:RENEE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W HAYCRAFT AVE
Mailing Address - Street 2:STE B3
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8105
Mailing Address - Country:US
Mailing Address - Phone:208-664-2468
Mailing Address - Fax:208-667-6239
Practice Address - Street 1:411 W HAYCRAFT AVE
Practice Address - Street 2:STE B3
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8105
Practice Address - Country:US
Practice Address - Phone:208-664-2468
Practice Address - Fax:208-667-6239
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-20612251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TD688OtherBLUE CROSS OF IDAHO
000010164610OtherREGENCE BLUE SHIELD
ID807908300Medicaid
TD688OtherBLUE CROSS OF IDAHO