Provider Demographics
NPI:1194448894
Name:ELLIS, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2018 EXETER RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3945
Mailing Address - Country:US
Mailing Address - Phone:901-756-4499
Mailing Address - Fax:
Practice Address - Street 1:2018 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3945
Practice Address - Country:US
Practice Address - Phone:901-756-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3246225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics