Provider Demographics
NPI:1093201808
Name:THRIVE PEDIATRIC FEEDING THERAPY LLC
Entity Type:Organization
Organization Name:THRIVE PEDIATRIC FEEDING THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:CLAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:812-470-6589
Mailing Address - Street 1:4120 BELLEMEADE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0612
Mailing Address - Country:US
Mailing Address - Phone:812-470-6589
Mailing Address - Fax:
Practice Address - Street 1:4120 BELLEMEADE AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0612
Practice Address - Country:US
Practice Address - Phone:812-470-6589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042290A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007710607Medicaid