Provider Demographics
NPI:1114424108
Name:ROUSSOS, ELSA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ELSA
Middle Name:
Last Name:ROUSSOS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CEDARHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3004
Mailing Address - Country:US
Mailing Address - Phone:347-699-4031
Mailing Address - Fax:
Practice Address - Street 1:511 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2737
Practice Address - Country:US
Practice Address - Phone:516-565-0388
Practice Address - Fax:516-565-2782
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty