Provider Demographics
NPI:1689664898
Name:CANONI, ELIZABETH JEAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JEAN
Last Name:CANONI
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:DODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:88 CONVERSE LN
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-5121
Mailing Address - Country:US
Mailing Address - Phone:781-632-5202
Mailing Address - Fax:
Practice Address - Street 1:388 PLEASANT ST
Practice Address - Street 2:SUITE 203
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8143
Practice Address - Country:US
Practice Address - Phone:781-388-0012
Practice Address - Fax:781-388-3312
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA112432251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67615OtherBCBS PROVIDER NUMBER
MA468857OtherTUFTS PROVIDER NUMBER
MAAA38236OtherHARVARD PILGRIM NUMBER
MAY67615OtherBCBS PROVIDER NUMBER