Provider Demographics
NPI:1215130232
Name:PETLEV, ELIZABETH ANN (MSCCCSLP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:PETLEV
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 STONE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33467-8335
Mailing Address - Country:US
Mailing Address - Phone:561-784-1745
Mailing Address - Fax:
Practice Address - Street 1:9291 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-3959
Practice Address - Country:US
Practice Address - Phone:561-955-5437
Practice Address - Fax:561-483-7044
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5629235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886163300Medicaid
FLSA5629OtherSTATE LICENCE