Provider Demographics
NPI:1538256458
Name:ELLEFSON THERAPY LTD
Entity type:Organization
Organization Name:ELLEFSON THERAPY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARMELO
Authorized Official - Middle Name:D
Authorized Official - Last Name:TENUTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-657-0222
Mailing Address - Street 1:1425 SUMMIT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3200
Mailing Address - Country:US
Mailing Address - Phone:262-542-1112
Mailing Address - Fax:262-542-7476
Practice Address - Street 1:1425 SUMMIT AVE STE 201
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3200
Practice Address - Country:US
Practice Address - Phone:262-542-1112
Practice Address - Fax:262-542-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40412900Medicaid
WI86504Medicare ID - Type Unspecified