Provider Demographics
NPI:1043697899
Name:HEVERN, ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HEVERN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E 3RD ST
Mailing Address - Street 2:APT #3
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-3232
Mailing Address - Country:US
Mailing Address - Phone:914-715-0128
Mailing Address - Fax:
Practice Address - Street 1:800 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-6015
Practice Address - Country:US
Practice Address - Phone:914-715-0128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140238232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer