Provider Demographics
NPI:1164863296
Name:SLACK, ELIZABETH M
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:SLACK
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 1:1900 S LACHANCE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-8022
Mailing Address - Country:US
Mailing Address - Phone:231-775-3081
Mailing Address - Fax:231-775-7740
Practice Address - Street 1:1900 S LACHANCE RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-8022
Practice Address - Country:US
Practice Address - Phone:231-775-3081
Practice Address - Fax:231-775-7740
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006851225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist