Provider Demographics
NPI:1760782767
Name:GEKONGE, ELSEBAH VANESSA (PTA)
Entity Type:Individual
Prefix:MS
First Name:ELSEBAH
Middle Name:VANESSA
Last Name:GEKONGE
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 1:13516 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1011
Mailing Address - Country:US
Mailing Address - Phone:315-601-1415
Mailing Address - Fax:
Practice Address - Street 1:20809 UNION TPKE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3235
Practice Address - Country:US
Practice Address - Phone:718-479-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8021642225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant