Provider Demographics
NPI:1023658374
Name:MACCOLLOM, ELAINE ROSEMARY (PT)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:ROSEMARY
Last Name:MACCOLLOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:ROSEMARY
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8140 BAYHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776-3321
Mailing Address - Country:US
Mailing Address - Phone:727-644-0403
Mailing Address - Fax:727-398-1372
Practice Address - Street 1:8140 BAYHAVEN DR
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-3321
Practice Address - Country:US
Practice Address - Phone:727-644-0403
Practice Address - Fax:727-398-1372
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist