Provider Demographics
NPI:1154770055
Name:WHITE, ELIZABETH (PTA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11534 LUCKYGEM DRI
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2116
Mailing Address - Country:US
Mailing Address - Phone:813-484-2817
Mailing Address - Fax:
Practice Address - Street 1:11534 LUCKYGEM DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2116
Practice Address - Country:US
Practice Address - Phone:813-484-2817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25651172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker