Provider Demographics
NPI:1275340341
Name:MINCEY, ELISHA (LMT)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:MINCEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10903 INDIAN HEAD HWY STE 502
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-4012
Mailing Address - Country:US
Mailing Address - Phone:240-462-4770
Mailing Address - Fax:
Practice Address - Street 1:10903 INDIAN HEAD HWY STE 502
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4012
Practice Address - Country:US
Practice Address - Phone:240-462-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06708225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist