Provider Demographics
NPI:1003820226
Name:PETRY-JOHNSON, ELIZABETH H
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:PETRY-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1361 W WADE HAMPTON BLVD STE F
Mailing Address - Street 2:PMB 207
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1200
Practice Address - Country:US
Practice Address - Phone:864-848-6339
Practice Address - Fax:864-848-7203
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC943423122OtherINSURANCE PROVIDER NUMBER
SCP00263714OtherMEDICARE RAILROAD NUMBER
SCP00263714OtherMEDICARE RAILROAD NUMBER