Healthcare Provider Details

I. General information

NPI: 1376190108
Provider Name (Legal Business Name): MICHELLE LEE ELROD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WHITE COLUMNS DR
ROLLA MO
65401-2044
US

IV. Provider business mailing address

14709 MARIES ROAD 518
VICHY MO
65580-7166
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-7766
  • Fax:
Mailing address:
  • Phone: 573-578-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2014011839
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: