Provider Demographics
NPI:1093917197
Name:DESIMONE, ELLEN MARIE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30976
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-0976
Mailing Address - Country:US
Mailing Address - Phone:912-663-1186
Mailing Address - Fax:
Practice Address - Street 1:2 JOHNNY MERCER BLVD
Practice Address - Street 2:APT. 113
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-3329
Practice Address - Country:US
Practice Address - Phone:912-663-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist