Provider Demographics
NPI:1245870666
Name:UPTON, ELLEN BAIRNSFATHER (PTA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:BAIRNSFATHER
Last Name:UPTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:CAMILLE
Other - Last Name:BAIRNSFATHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:671 GRANTS FERRY RD STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6801
Mailing Address - Country:US
Mailing Address - Phone:769-777-4400
Mailing Address - Fax:769-777-4401
Practice Address - Street 1:671 GRANTS FERRY RD STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6801
Practice Address - Country:US
Practice Address - Phone:769-777-4400
Practice Address - Fax:769-777-4401
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA7066225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant