Provider Demographics
NPI:1134693633
Name:ROMAN, ELISE (OT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-3908
Mailing Address - Fax:304-329-3918
Practice Address - Street 1:150 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1141
Practice Address - Country:US
Practice Address - Phone:304-329-3908
Practice Address - Fax:304-329-3918
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1981225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist