Provider Demographics
NPI:1588695670
Name:MARR, ELIZABETH L (PT, PHD,DPT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:MARR
Suffix:
Gender:F
Credentials:PT, PHD,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 MCCULLOCH BLVD N STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6559
Mailing Address - Country:US
Mailing Address - Phone:285-055-6919
Mailing Address - Fax:
Practice Address - Street 1:1760 MCCULLOCH BLVD N STE 200
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:285-055-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2641225100000X
IN05012355A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172166Medicaid
AZZ110836Medicare PIN
P13036Medicare UPIN