Healthcare Provider Details

I. General information

NPI: 1790017630
Provider Name (Legal Business Name): ELLEN WHEALTON MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 TEHAMA CT
AUSTIN TX
78738-5425
US

IV. Provider business mailing address

3221 TEHAMA CT
AUSTIN TX
78738-5425
US

V. Phone/Fax

Practice location:
  • Phone: 512-402-0977
  • Fax:
Mailing address:
  • Phone: 512-402-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number09176
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: