Provider Demographics
NPI:1306148804
Name:DUMONT, ELIZABETH MARIE (PTA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:DUMONT
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 1:1113 SUNNYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8736
Mailing Address - Country:US
Mailing Address - Phone:231-492-2088
Mailing Address - Fax:
Practice Address - Street 1:844 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:LA JOYA
Practice Address - State:TX
Practice Address - Zip Code:78560-4178
Practice Address - Country:US
Practice Address - Phone:956-688-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002957225200000X
TX2079632225200000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist