Healthcare Provider Details

I. General information

NPI: 1275747016
Provider Name (Legal Business Name): PHILIP ELSAS ITDS CERTIFIED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101-1 COLLEGE ST
JACKSONVILLE FL
32205-5318
US

IV. Provider business mailing address

4101-1 COLLEGE ST
JACKSONVILLE FL
32205-5318
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-0370
  • Fax: 904-387-0156
Mailing address:
  • Phone: 904-387-0370
  • Fax: 904-387-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: