Provider Demographics
NPI:1215060694
Name:ELTZROTH, MARGARET PENDLEY (LLC)
Entity type:Individual
Prefix:MRS
First Name:MARGARET
Middle Name:PENDLEY
Last Name:ELTZROTH
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W BUENA VISTA RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-5185
Mailing Address - Country:US
Mailing Address - Phone:812-429-0399
Mailing Address - Fax:812-429-0708
Practice Address - Street 1:1202 W BUENA VISTA ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-5185
Practice Address - Country:US
Practice Address - Phone:812-429-0399
Practice Address - Fax:812-429-0708
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001189A101YA0400X
35000576A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000331532OtherANTHEM
IN000000331532OtherANTHEM