Provider Demographics
NPI:1558061820
Name:DZAMBASOW, ELISSA KATHERINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:KATHERINE
Last Name:DZAMBASOW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 BYNUM VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-3024
Mailing Address - Country:US
Mailing Address - Phone:443-567-0998
Mailing Address - Fax:
Practice Address - Street 1:1750 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1534
Practice Address - Country:US
Practice Address - Phone:443-923-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist