Provider Demographics
NPI:1457593360
Name:ELLIOTT, DESIREE MARIA (DPT)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MARIA
Last Name:ELLIOTT
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 1:160 THEODORE FREMD AVE
Mailing Address - Street 2:APT B13
Mailing Address - City:RYE
Mailing Address - State:NY
Mailing Address - Zip Code:10580-2850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3852
Practice Address - Country:US
Practice Address - Phone:203-855-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT066068853OtherEMPLOYER IDENTIFICATION NUMBER