Provider Demographics
NPI:1275678229
Name:DEJONG, ELS (RPT)
Entity Type:Individual
Prefix:
First Name:ELS
Middle Name:
Last Name:DEJONG
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:ELS
Other - Middle Name:
Other - Last Name:O'ROURKE-DEJONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPT
Mailing Address - Street 1:1069 SHELDON FLATS RD
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-8967
Mailing Address - Country:US
Mailing Address - Phone:406-283-1003
Mailing Address - Fax:
Practice Address - Street 1:1069 SHELDON FLATS RD
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-8967
Practice Address - Country:US
Practice Address - Phone:406-283-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5152454834Medicare ID - Type Unspecified