Provider Demographics
NPI:1841944519
Name:ELDER ATHLETE PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:ELDER ATHLETE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:727-380-4887
Mailing Address - Street 1:400 4TH AVE S APT 106
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4621
Mailing Address - Country:US
Mailing Address - Phone:727-380-4887
Mailing Address - Fax:727-290-4328
Practice Address - Street 1:490 1ST AVE S STE 220
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4287
Practice Address - Country:US
Practice Address - Phone:727-380-4887
Practice Address - Fax:727-290-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty