Provider Demographics
NPI:1255720462
Name:POTTKOTTER, ELISE (DPT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:POTTKOTTER
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 1:6600 STATE ROUTE 274
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-9567
Mailing Address - Country:US
Mailing Address - Phone:419-305-5964
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5185
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist