Provider Demographics
NPI:1366635260
Name:FRASER, ELISA (PT)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:FRASER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SHAPLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1455
Mailing Address - Country:US
Mailing Address - Phone:207-439-8939
Mailing Address - Fax:207-439-8940
Practice Address - Street 1:22 SHAPLEIGH RD
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1455
Practice Address - Country:US
Practice Address - Phone:207-439-8939
Practice Address - Fax:207-439-8940
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist