Provider Demographics
NPI:1962078709
Name:PEDEAUX, ELLEN DEAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DEAN
Last Name:PEDEAUX
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:ANDRIES
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:663 JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4748
Mailing Address - Country:US
Mailing Address - Phone:318-222-8892
Mailing Address - Fax:318-222-8893
Practice Address - Street 1:4970 BARKSDALE BLVD STE 900
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4677
Practice Address - Country:US
Practice Address - Phone:318-747-8892
Practice Address - Fax:318-747-8893
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
LA09898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist