Provider Demographics
NPI:1922388024
Name:ELIMON, TY (MSED)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:ELIMON
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:TK
Other - Middle Name:
Other - Last Name:ELIMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7201 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3023
Practice Address - Country:US
Practice Address - Phone:618-925-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist