Provider Demographics
NPI:1386778132
Name:ELLIS, BRENNA D (MS,ATC,LAT)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS,ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8603 N LOOP 1604 W
Mailing Address - Street 2:#12235
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2601
Mailing Address - Country:US
Mailing Address - Phone:210-481-8401
Mailing Address - Fax:
Practice Address - Street 1:UTSA ATHLETICS
Practice Address - Street 2:ONE UTSA CIRCLE
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-0691
Practice Address - Country:US
Practice Address - Phone:210-458-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT25422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer