Provider Demographics
NPI:1285895458
Name:ELLIS, KELLE JO (LMP)
Entity type:Individual
Prefix:
First Name:KELLE JO
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 SOUTH 24TH STREET WEST
Mailing Address - Street 2:STE A
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102
Mailing Address - Country:US
Mailing Address - Phone:406-652-7000
Mailing Address - Fax:406-652-7002
Practice Address - Street 1:993 SOUTH 24TH STREET WEST
Practice Address - Street 2:STE A
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-652-7000
Practice Address - Fax:406-652-7002
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist