Provider Demographics
NPI:1952374126
Name:DE JONG, ELISABETH ANN (PT)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ANN
Last Name:DE JONG
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 1:504 ALBEMARLE SQ
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-7405
Mailing Address - Country:US
Mailing Address - Phone:434-817-7848
Mailing Address - Fax:434-465-6834
Practice Address - Street 1:504 ALBEMARLE SQ
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-7405
Practice Address - Country:US
Practice Address - Phone:434-817-7848
Practice Address - Fax:434-951-2194
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010272718Medicaid
VA010272718Medicaid