Provider Demographics
NPI:1316286511
Name:EWAN, ELISSA SUSAN (DPT)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:SUSAN
Last Name:EWAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3901 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3948
Mailing Address - Country:US
Mailing Address - Phone:715-907-0900
Mailing Address - Fax:715-803-6977
Practice Address - Street 1:3901 STEWART AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3948
Practice Address - Country:US
Practice Address - Phone:715-841-0002
Practice Address - Fax:715-841-0003
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12167-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028871Medicaid