Provider Demographics
NPI:1386766335
Name:ELLWOOD, HEIDI LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:LYNN
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20270 HARLEQUIN LN
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-7524
Mailing Address - Country:US
Mailing Address - Phone:573-336-4965
Mailing Address - Fax:
Practice Address - Street 1:20270 HARLEQUIN LN
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-7524
Practice Address - Country:US
Practice Address - Phone:573-336-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019387174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist