Provider Demographics
NPI:1033251327
Name:WHITE, ELISE A (DPT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:3243 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-4835
Practice Address - Country:US
Practice Address - Phone:812-668-1880
Practice Address - Fax:812-668-1881
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34746225100000X
IL070013153225100000X
IN05010313A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201064510Medicaid
IN201064510Medicaid