Provider Demographics
NPI:1407594096
Name:DEEN, ELSA TANA
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:TANA
Last Name:DEEN
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 1:2332 BATTLEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2728
Mailing Address - Country:US
Mailing Address - Phone:314-616-5285
Mailing Address - Fax:
Practice Address - Street 1:11861 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3305
Practice Address - Country:US
Practice Address - Phone:314-392-9762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015042182225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist