Provider Demographics
NPI:1730913211
Name:RADEMACHER, ELISA MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE
Last Name:RADEMACHER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 VISTA LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0078
Mailing Address - Country:US
Mailing Address - Phone:443-756-7410
Mailing Address - Fax:
Practice Address - Street 1:9803 OLD SAINT AUGUSTINE RD STE 7
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8845
Practice Address - Country:US
Practice Address - Phone:904-880-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA22914235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist