Provider Demographics
NPI:1396865366
Name:STAFFORD, ELYSE CLAIRE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ELYSE
Middle Name:CLAIRE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-5127
Mailing Address - Country:US
Mailing Address - Phone:805-660-2623
Mailing Address - Fax:805-499-9106
Practice Address - Street 1:575 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-5127
Practice Address - Country:US
Practice Address - Phone:805-660-2623
Practice Address - Fax:805-499-9106
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 936225200000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner