Provider Demographics
NPI:1447923313
Name:GIBBONS, ELYSSA ANN (DPT)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:ANN
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELYSSA
Other - Middle Name:
Other - Last Name:EICHELBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1731 DANIEL BOONE LN
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2864
Mailing Address - Country:US
Mailing Address - Phone:660-537-3908
Mailing Address - Fax:
Practice Address - Street 1:1731 DANIEL BOONE LN
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2864
Practice Address - Country:US
Practice Address - Phone:660-537-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist