Provider Demographics
NPI:1497074496
Name:KOOTA, ELISHA DEBORAH (AP)
Entity Type:Individual
Prefix:MS
First Name:ELISHA
Middle Name:DEBORAH
Last Name:KOOTA
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 NW 35TH ST # 1521
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-2408
Mailing Address - Country:US
Mailing Address - Phone:954-464-8757
Mailing Address - Fax:
Practice Address - Street 1:3841 NW 35TH ST # 1521
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-2408
Practice Address - Country:US
Practice Address - Phone:954-464-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2833171100000X
FLMA43216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist