Provider Demographics
NPI:1881945566
Name:ELLIS, ROBERT RAY (DPT)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 CASSIMER AVE
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2309
Mailing Address - Country:US
Mailing Address - Phone:228-326-1115
Mailing Address - Fax:
Practice Address - Street 1:4016 CASSIMER AVE
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2309
Practice Address - Country:US
Practice Address - Phone:228-326-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5070171000000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider