MEDICARE: ELEMENTAL PHYSICAL THERAPY, PLLC

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639879935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEMENTAL PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	22 BITTERSWEET LN
Second Line	:
City	:	SLINGERLANDS
State	:	NY
Zip	:	12159-9424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 NORMANSKILL BLVD STE 206
Second Line	:
City	:	DELMAR
State	:	NY
Zip	:	12054-1331
Country	:	US
Telephone Number	:	518-212-7515
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	JACQUELINE SWENSON
Credential	:
Telephone Number	:	518-212-7515

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/06/2023

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