Provider Demographics
NPI:1750657367
Name:SMITH, ELENA M (PTA)
Entity Type:Individual
Prefix:MS
First Name:ELENA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WELLS CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3042
Mailing Address - Country:US
Mailing Address - Phone:973-338-0623
Mailing Address - Fax:
Practice Address - Street 1:250 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5689
Practice Address - Country:US
Practice Address - Phone:973-743-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00262100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant