Provider Demographics
NPI:1376997726
Name:PACHOLEWSKI, ELISE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:PACHOLEWSKI
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W BROADWAY
Mailing Address - Street 2:APT 110
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1270
Mailing Address - Country:US
Mailing Address - Phone:216-310-8549
Mailing Address - Fax:
Practice Address - Street 1:501 WESTMINSTER AVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1230
Practice Address - Country:US
Practice Address - Phone:573-592-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002148390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program