Provider Demographics
NPI:1871802124
Name:ELSBACH, AMELIA MARIA (PT)
Entity type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:MARIA
Last Name:ELSBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:AMELIA
Other - Middle Name:MARIA
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:726 JAMESPORT DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-4399
Mailing Address - Country:US
Mailing Address - Phone:636-294-2737
Mailing Address - Fax:
Practice Address - Street 1:12115 BRIDGETON SQ
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2616
Practice Address - Country:US
Practice Address - Phone:314-291-8380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011325225100000X
MO118190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist