MEDICARE: EMMAGAIL GRACE ELAM PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2022041230	MO

General Provider Information

NPI Number	:	1184499691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMAGAIL GRACE ELAM PTA

Provider Business Mailing Address
First Line	:	25227 US HIGHWAY 136
Second Line	:
City	:	KAHOKA
State	:	MO
Zip	:	63445-2015
Country	:	US
Telephone Number	:	660-341-2448
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 S JOHNSON ST
Second Line	:
City	:	KAHOKA
State	:	MO
Zip	:	63445-1657
Country	:	US
Telephone Number	:	660-727-2722
Fax Number	:	660-727-2725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	11/15/2023

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Directions to “ EMMAGAIL GRACE ELAM PTA” Practice Location

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