Provider Demographics
NPI:1538690508
Name:ROBERTSON, ELYSE (LMT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 NE 6TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-3731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1326 NE 6TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-3731
Practice Address - Country:US
Practice Address - Phone:352-575-0593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA81786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist