Provider Demographics
NPI:1043753064
Name:ROALEF, ELYSE (LMT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:ROALEF
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BIRDSALL ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-2034
Mailing Address - Country:US
Mailing Address - Phone:607-336-1116
Mailing Address - Fax:
Practice Address - Street 1:116 BIRDSALL ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-2034
Practice Address - Country:US
Practice Address - Phone:607-336-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27029730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY27029730OtherMASSAGE LICENSE