Provider Demographics
NPI:1063889384
Name:ELIE, JEAN PATRICK (MT)
Entity type:Individual
Prefix:MR
First Name:JEAN
Middle Name:PATRICK
Last Name:ELIE
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ROCKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4745
Mailing Address - Country:US
Mailing Address - Phone:516-587-3337
Mailing Address - Fax:
Practice Address - Street 1:672 WELLWOOD AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1677
Practice Address - Country:US
Practice Address - Phone:561-225-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028512-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist