Provider Demographics
NPI:1962992602
Name:ELLERY, SANDRA KATHRYN (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KATHRYN
Last Name:ELLERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MI
Mailing Address - Zip Code:48611-9320
Mailing Address - Country:US
Mailing Address - Phone:989-980-2246
Mailing Address - Fax:
Practice Address - Street 1:500 S HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-1511
Practice Address - Country:US
Practice Address - Phone:989-799-6020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002289225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty