Basic Information
| Provider Information | |||||||||
| NPI: | 1376865626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BASS | ||||||||
| OtherFirstName: | LORA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7381 S SIWELL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392728741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013732075 | ||||||||
| FaxNumber: | 6013732077 | ||||||||
| Practice Location | |||||||||
| Address1: | 7381 S SIWELL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392728741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013732075 | ||||||||
| FaxNumber: | 6013732077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2010 | ||||||||
| LastUpdateDate: | 02/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4540 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.