Provider Demographics
NPI:1003473182
Name:THATCHER, ELISABETH (PTA)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:THATCHER
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 1:74-5065 PALANI RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-8118
Mailing Address - Country:US
Mailing Address - Phone:808-990-4823
Mailing Address - Fax:
Practice Address - Street 1:70 SW CENTURY DR STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3558
Practice Address - Country:US
Practice Address - Phone:808-990-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60839352225200000X
OR09683225200000X
ID4803225200000X
HI333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant