Provider Demographics
NPI:1396099875
Name:MENCK, ELISA S (DPT)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:S
Last Name:MENCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5000
Mailing Address - Country:US
Mailing Address - Phone:904-524-9545
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214
Practice Address - Country:US
Practice Address - Phone:904-542-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052074462251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic