Provider Demographics
NPI:1366814527
Name:IRONSIDE, ELIZABETH (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:IRONSIDE
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 1:1041 HILL STREET
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5221
Mailing Address - Country:US
Mailing Address - Phone:715-424-8500
Mailing Address - Fax:
Practice Address - Street 1:1041 HILL ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5221
Practice Address - Country:US
Practice Address - Phone:715-424-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13232-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist