Provider Demographics
NPI:1053703355
Name:ELLIOTT, ERIC GABRIEL (LMT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:GABRIEL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W FIRTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-1909
Mailing Address - Country:US
Mailing Address - Phone:267-535-0123
Mailing Address - Fax:
Practice Address - Street 1:340 E MAPLE AVE
Practice Address - Street 2:SUITE 204 C
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-2850
Practice Address - Country:US
Practice Address - Phone:267-535-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG007283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist