Provider Demographics
NPI:1093921520
Name:KOSEMPA, ELISBETH SUSAN
Entity Type:Individual
Prefix:
First Name:ELISBETH
Middle Name:SUSAN
Last Name:KOSEMPA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-1025
Mailing Address - Country:US
Mailing Address - Phone:406-208-3203
Mailing Address - Fax:
Practice Address - Street 1:6551 PARK OF COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-8218
Practice Address - Country:US
Practice Address - Phone:800-347-2264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21924225100000X
MT1706225100000X
NC10769225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist