Provider Demographics
NPI:1841460359
Name:ELLIS, LISA K (MSR, PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSR, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GAULT AVE S
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-1626
Mailing Address - Country:US
Mailing Address - Phone:256-844-2992
Mailing Address - Fax:
Practice Address - Street 1:600 GAULT AVE S
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-1626
Practice Address - Country:US
Practice Address - Phone:256-844-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5238225100000X
GA7197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist