Provider Demographics
NPI:1053898759
Name:ELLIS, HEATHER RENEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:62 CARRIAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290
Practice Address - Country:US
Practice Address - Phone:770-969-7166
Practice Address - Fax:770-969-7168
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCP022961T225100000X
SCCP030242T225100000X
VACP022960T225100000X
OHCP024110T225100000X
KST-W0035-3225100000X
TN15271225100000X
GAPT013604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist