Provider Demographics
NPI:1629587233
Name:MINAMIDE, ELYSE HARUKO (PT, DPT, NCS)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:HARUKO
Last Name:MINAMIDE
Suffix:
Gender:F
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:HARUKO
Other - Last Name:MINAMIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38 MILAGRO
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2882
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14851 YORBA ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2925
Practice Address - Country:US
Practice Address - Phone:714-832-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376282251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology