Provider Demographics
NPI:1720479702
Name:ELLIS, KELSEY E (PT DPT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:E
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 1:1401 GATEWAY BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6717
Mailing Address - Country:US
Mailing Address - Phone:307-352-3626
Mailing Address - Fax:307-352-3628
Practice Address - Street 1:1401 GATEWAY BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6717
Practice Address - Country:US
Practice Address - Phone:307-352-3626
Practice Address - Fax:307-352-3628
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1563225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist