Provider Demographics
NPI:1073054201
Name:ELAZEGUI CULANAG, CHARISSA (PT)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ELAZEGUI CULANAG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:
Other - Last Name:ELAZEGUI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5811 PERSIMMON DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-2016
Mailing Address - Country:US
Mailing Address - Phone:432-352-5900
Mailing Address - Fax:
Practice Address - Street 1:5811 PERSIMMON DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-2016
Practice Address - Country:US
Practice Address - Phone:432-352-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1210950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist