Provider Demographics
NPI:1417583238
Name:KENDALL, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KENDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 VAN NESS AVE PO BOX # 111
Mailing Address - Street 2:STE 120
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721
Mailing Address - Country:US
Mailing Address - Phone:617-528-9675
Mailing Address - Fax:
Practice Address - Street 1:700 VAN NESS AVE PO BOX # 111
Practice Address - Street 2:STE 120
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:617-528-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2024-06-12
Deactivation Date:2024-03-13
Deactivation Code:
Reactivation Date:2024-06-07
Provider Licenses
StateLicense IDTaxonomies
CA25731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497760086Medicaid