Provider Demographics
NPI:1013450790
Name:TILL, ELISSA (ATC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:TILL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-3829
Mailing Address - Country:US
Mailing Address - Phone:814-242-8797
Mailing Address - Fax:
Practice Address - Street 1:450 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2912
Practice Address - Country:US
Practice Address - Phone:814-269-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0038732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer