Healthcare Provider Details

I. General information

NPI: 1629358387
Provider Name (Legal Business Name): KEISHA ELLIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LAURA SUE HUMPHRESS DR
CAMPBELLSVILLE KY
42718-8899
US

IV. Provider business mailing address

514 TURKEY RUN RD
CAMPBELLSVILLE KY
42718-4929
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-7768
  • Fax: 270-465-0068
Mailing address:
  • Phone: 270-463-6173
  • Fax: 270-465-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003910
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: