Provider Demographics
NPI:1699836106
Name:ELSENRAAT, BLAINE G (MPT)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:G
Last Name:ELSENRAAT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 LOMBARD LN
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2055
Mailing Address - Country:US
Mailing Address - Phone:314-753-5116
Mailing Address - Fax:
Practice Address - Street 1:1212 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3325
Practice Address - Country:US
Practice Address - Phone:573-701-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist