Provider Demographics
NPI:1275011843
Name:FJELDHEIM, ELISSA
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:FJELDHEIM
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 1:2026 E PATRICK LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-7538
Mailing Address - Country:US
Mailing Address - Phone:407-446-5854
Mailing Address - Fax:
Practice Address - Street 1:9385 W DONALD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2988
Practice Address - Country:US
Practice Address - Phone:407-446-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist