Provider Demographics
NPI:1104113935
Name:ELLENBURG, SHASTA J (PT)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:J
Last Name:ELLENBURG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-236-2774
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:1254 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3712
Practice Address - Country:US
Practice Address - Phone:334-445-1380
Practice Address - Fax:334-445-1489
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist