Provider Demographics
NPI:1205596400
Name:RONDA, ELYSSA LORAINNE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:LORAINNE
Last Name:RONDA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5696 ANDREWS DR APT 8
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7013
Mailing Address - Country:US
Mailing Address - Phone:310-490-8787
Mailing Address - Fax:
Practice Address - Street 1:4920 E STATE ST STE 4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2262
Practice Address - Country:US
Practice Address - Phone:815-637-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014661225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist