Provider Demographics
NPI:1760057111
Name:DIMATTIA, ELENA (DPT)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:DIMATTIA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ZACHARY DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-5332
Mailing Address - Country:US
Mailing Address - Phone:337-706-1142
Mailing Address - Fax:337-706-1177
Practice Address - Street 1:1490 MARKET ST STE 2
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-3850
Practice Address - Country:US
Practice Address - Phone:337-990-5621
Practice Address - Fax:337-990-5623
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist