Provider Demographics
NPI:1083032890
Name:CULBERSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CULBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E NEWBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ROMEO
Mailing Address - State:MI
Mailing Address - Zip Code:48065-4769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 E NEWBERRY ST
Practice Address - Street 2:
Practice Address - City:ROMEO
Practice Address - State:MI
Practice Address - Zip Code:48065-4769
Practice Address - Country:US
Practice Address - Phone:586-634-9939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI6801099431104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other