Basic Information
| Provider Information | |||||||||
| NPI: | 1720479702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PT DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 GATEWAY BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829016717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073523626 | ||||||||
| FaxNumber: | 3073523628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 GATEWAY BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829016717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073523626 | ||||||||
| FaxNumber: | 3073523628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1563 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.