Healthcare Provider Details

I. General information

NPI: 1700968864
Provider Name (Legal Business Name): MICHELLE C ELLISON P. T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE C LEE P.T.

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 NISSAN PKWY SUITE 400, BLDG F
CANTON MS
39046-7006
US

IV. Provider business mailing address

2416 HIGHWAY 45 N
COLUMBUS MS
39705-1320
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-3776
  • Fax: 601-859-3778
Mailing address:
  • Phone: 662-327-6705
  • Fax: 662-327-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberMS PT0747
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: