Basic Information
| Provider Information | |||||||||
| NPI: | 1104011949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2806 FOUNTAIN PLAZA BLVD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785398031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563162224 | ||||||||
| FaxNumber: | 9563160445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1403 N. SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780408752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566831155 | ||||||||
| FaxNumber: | 9566831188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 05/19/2010 | ||||||||
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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 | 1075695 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.