Provider Demographics
NPI:1699915637
Name:RALEY, ELISABETH VICTORIA (LMT)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:VICTORIA
Last Name:RALEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:ELISABETH
Other - Middle Name:VICTORIA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:601 RIVERHILL CIR APT B3
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8131
Mailing Address - Country:US
Mailing Address - Phone:803-622-6569
Mailing Address - Fax:
Practice Address - Street 1:1531 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6128
Practice Address - Country:US
Practice Address - Phone:803-622-6569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist