Provider Demographics
NPI:1215612627
Name:ELEVATED PHYSICAL THERAPY AND MOVEMENT
Entity type:Organization
Organization Name:ELEVATED PHYSICAL THERAPY AND MOVEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:928-220-7504
Mailing Address - Street 1:2797 W PICO DEL MONTE CIR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9199
Mailing Address - Country:US
Mailing Address - Phone:928-607-4037
Mailing Address - Fax:
Practice Address - Street 1:2529 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3722
Practice Address - Country:US
Practice Address - Phone:928-220-7504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty