Basic Information
| Provider Information | |||||||||
| NPI: | 1700968864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P. T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2416 HIGHWAY 45 N | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397051320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 276 NISSAN PKWY | ||||||||
| Address2: | SUITE 400, BLDG F | ||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390467006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018593776 | ||||||||
| FaxNumber: | 6018593778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
| 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 | MS PT0747 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5965404 | 01 | MS | AETNA | OTHER |