Provider Demographics
NPI:1952982415
Name:GOLDENSE, ELLIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:GOLDENSE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 98 PALMS BLVD UNIT 4221
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2777
Mailing Address - Country:US
Mailing Address - Phone:508-259-9898
Mailing Address - Fax:
Practice Address - Street 1:814 TULLY ST
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5744
Practice Address - Country:US
Practice Address - Phone:850-312-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0041942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer