Provider Demographics
NPI:1700499019
Name:LANDESBERG, ELYSE (PT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:LANDESBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ALEWIFE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-3801
Mailing Address - Country:US
Mailing Address - Phone:860-439-1323
Mailing Address - Fax:
Practice Address - Street 1:40 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2424
Practice Address - Country:US
Practice Address - Phone:860-271-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46352251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics