Provider Demographics
NPI:1093332330
Name:HEUSTIS, ELIZABETH (LMT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:HEUSTIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:BRODBECK HEUSTIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1012 BLUEGRASS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2314
Mailing Address - Country:US
Mailing Address - Phone:502-457-6431
Mailing Address - Fax:
Practice Address - Street 1:1012 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2314
Practice Address - Country:US
Practice Address - Phone:502-457-6431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1715407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty