=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700627072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN ELYSSE WELLS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10815 RANCH ROAD 2222 BLDG 3B #200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78730-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-614-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12000 DESSAU RD APT 615
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78754-2094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-822-2458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 3133081
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------