Provider Demographics
NPI:1104850239
Name:PETTIT, ELIZABETH M (DPT)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:PETTIT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1764
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621
Mailing Address - Country:US
Mailing Address - Phone:970-927-9319
Mailing Address - Fax:970-927-0168
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 203 ROARING FORK PT
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621
Practice Address - Country:US
Practice Address - Phone:970-927-9319
Practice Address - Fax:970-927-0168
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
066577Medicare ID - Type Unspecified