Provider Demographics
NPI:1841264777
Name:DUNCANSON, ELIZABETH GILLEM (PT, ATC, CSCS, PYT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GILLEM
Last Name:DUNCANSON
Suffix:
Gender:F
Credentials:PT, ATC, CSCS, PYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 - 51ST STREET
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-708-8703
Mailing Address - Fax:
Practice Address - Street 1:391 51ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2256
Practice Address - Country:US
Practice Address - Phone:510-708-8703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27612225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT276120Medicare ID - Type Unspecified