Provider Demographics
NPI:1871205120
Name:ELBODE, ALYSE M (PTA)
Entity type:Individual
Prefix:MRS
First Name:ALYSE
Middle Name:M
Last Name:ELBODE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12388 FRANK DR
Mailing Address - Street 2:
Mailing Address - City:ROMEO
Mailing Address - State:MI
Mailing Address - Zip Code:48065-4490
Mailing Address - Country:US
Mailing Address - Phone:586-746-9845
Mailing Address - Fax:
Practice Address - Street 1:210 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1774
Practice Address - Country:US
Practice Address - Phone:866-812-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005882225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant