Provider Demographics
NPI:1427337500
Name:ELLIS, TONYA M (PT, DPT)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 CENTRAL PARKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6852
Mailing Address - Country:US
Mailing Address - Phone:513-701-6100
Mailing Address - Fax:
Practice Address - Street 1:2859 BOUDINOT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-1606
Practice Address - Country:US
Practice Address - Phone:513-701-6520
Practice Address - Fax:513-701-6521
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.012729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214940Medicaid
OH366632Medicare PIN