Provider Demographics
NPI:1184453953
Name:ROUSE, ELISSA (ATC)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:ROUSE
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 1:164 PLANTATION DR E
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-9059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 PLANTATION DR E
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-9059
Practice Address - Country:US
Practice Address - Phone:501-691-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0697023892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer