Provider Demographics
NPI:1174917488
Name:ELSTON, LAVONNE (PT)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:ELSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7809 N MOON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-7843
Mailing Address - Country:US
Mailing Address - Phone:419-343-7799
Mailing Address - Fax:
Practice Address - Street 1:345 E BOUNDARY ST
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2760
Practice Address - Country:US
Practice Address - Phone:419-873-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist