Provider Demographics
NPI:1235772336
Name:PAVLET, ELISA BETH
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:BETH
Last Name:PAVLET
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 1:1801 S JENTILLY LN STE C16
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-5760
Mailing Address - Country:US
Mailing Address - Phone:602-561-8711
Mailing Address - Fax:
Practice Address - Street 1:1801 S JENTILLY LN STE C16
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5760
Practice Address - Country:US
Practice Address - Phone:602-561-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-10186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty