Provider Demographics
NPI:1669935300
Name:GATHENYA, ELIAS
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:GATHENYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15828 CLARENDON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7877
Mailing Address - Country:US
Mailing Address - Phone:574-612-8394
Mailing Address - Fax:
Practice Address - Street 1:17475 DUGDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1545
Practice Address - Country:US
Practice Address - Phone:574-247-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002567A224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing