Provider Demographics
NPI:1992001812
Name:RAYMOND, ILISSA L (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ILISSA
Middle Name:L
Last Name:RAYMOND
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 1:522 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1933
Mailing Address - Country:US
Mailing Address - Phone:607-426-6159
Mailing Address - Fax:
Practice Address - Street 1:500 ACADEMY ST S
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3248
Practice Address - Country:US
Practice Address - Phone:252-209-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist