Provider Demographics
NPI:1750413522
Name:GILLUM, ELISHA ANNE (MPT)
Entity type:Individual
Prefix:MRS
First Name:ELISHA
Middle Name:ANNE
Last Name:GILLUM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1868 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-1573
Mailing Address - Country:US
Mailing Address - Phone:636-464-6016
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:MEDICAID DEPARTMENT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-345-2535
Practice Address - Fax:314-345-2653
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010083152251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics