Provider Demographics
NPI:1700166154
Name:CONEJO, ELIS RAQUEL (DPT)
Entity type:Individual
Prefix:DR
First Name:ELIS
Middle Name:RAQUEL
Last Name:CONEJO
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 1:6553 E. BAYWOOD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-396-9922
Mailing Address - Fax:480-396-2429
Practice Address - Street 1:6553 E. BAYWOOD
Practice Address - Street 2:SUITE 205
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-396-9922
Practice Address - Fax:480-396-2429
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ94672251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic