Basic Information
| Provider Information | |||||||||
| NPI: | 1093980047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELMORE | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATTERSON | ||||||||
| OtherFirstName: | MISTY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 450 NEW MARKET BLVD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283559584 | ||||||||
| FaxNumber: | 8283559689 | ||||||||
| Practice Location | |||||||||
| Address1: | 3703 WEST LAKE AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056007320 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.