Basic Information
| Provider Information | |||||||||
| NPI: | 1871133876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELEVATE THERAPY & PERFORMANCE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 W FREEMAN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629012809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124911307 | ||||||||
| FaxNumber: | 6185490226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOERFLEIN | ||||||||
| AuthorizedOfficialFirstName: | CODY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6185490225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070024815 | 01 | IL | STATE LICENSE | OTHER |