Healthcare Provider Details

I. General information

NPI: 1467549956
Provider Name (Legal Business Name): ELISSA SUZANNE HOOPER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5949 W RAYMOND ST
INDIANAPOLIS IN
46241-4348
US

IV. Provider business mailing address

718 GREEN RIDGE PKWY APT B
BROWNSBURG IN
46112-2446
US

V. Phone/Fax

Practice location:
  • Phone: 317-390-5590
  • Fax: 317-486-2194
Mailing address:
  • Phone: 217-495-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.001946
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number360010277A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: