Healthcare Provider Details

I. General information

NPI: 1255571485
Provider Name (Legal Business Name): CATHERINE ANN JELLIE P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 W HIBISCUS BLVD SUITE A
MELBOURNE FL
32901-2639
US

IV. Provider business mailing address

1698 W HIBISCUS BLVD SUITE A
MELBOURNE FL
32901-2639
US

V. Phone/Fax

Practice location:
  • Phone: 321-768-6119
  • Fax: 321-768-1710
Mailing address:
  • Phone: 321-768-6119
  • Fax: 321-768-1710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: