Provider Demographics
NPI:1275955601
Name:CHILDRESS, ELIZABETH (PTA)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S IH 35
Mailing Address - Street 2:SUITE L-2
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-6900
Mailing Address - Country:US
Mailing Address - Phone:512-529-7239
Mailing Address - Fax:
Practice Address - Street 1:2000 S IH 35
Practice Address - Street 2:SUITE L-2
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-6900
Practice Address - Country:US
Practice Address - Phone:512-529-7239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096972225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant