Healthcare Provider Details

I. General information

NPI: 1184499691
Provider Name (Legal Business Name): EMMAGAIL GRACE ELAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/15/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S JOHNSON ST
KAHOKA MO
63445-1657
US

IV. Provider business mailing address

25227 US HIGHWAY 136
KAHOKA MO
63445-2015
US

V. Phone/Fax

Practice location:
  • Phone: 660-727-2722
  • Fax: 660-727-2725
Mailing address:
  • Phone: 660-341-2448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2022041230
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: