Provider Demographics
NPI:1912361007
Name:KORTUS, ELICIA
Entity Type:Individual
Prefix:
First Name:ELICIA
Middle Name:
Last Name:KORTUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELICIA
Other - Middle Name:
Other - Last Name:MADETZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:900 S GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4533
Mailing Address - Country:US
Mailing Address - Phone:605-951-9981
Mailing Address - Fax:
Practice Address - Street 1:401 E 8TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-7009
Practice Address - Country:US
Practice Address - Phone:605-951-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT10034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist