Basic Information
| Provider Information | |||||||||
| NPI: | 1215665823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERUSKA | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003411703 | ||||||||
| FaxNumber: | 8777194609 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 W LINCOLN HWY STE 110E | ||||||||
| Address2: | |||||||||
| City: | SCHERERVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463754606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2195156993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2022 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06006496A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 06006496A | 01 | IN | PTA LICENSE | OTHER |