Provider Demographics
NPI:1861974792
Name:ELLERD, JIM THOMAS (PTA)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:THOMAS
Last Name:ELLERD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-3233
Mailing Address - Country:US
Mailing Address - Phone:806-894-5053
Mailing Address - Fax:
Practice Address - Street 1:210 WEST AVE
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-3233
Practice Address - Country:US
Practice Address - Phone:806-894-5053
Practice Address - Fax:806-894-9603
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2031342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant