Provider Demographics
NPI:1326767195
Name:EASTMAN, ELIZABETH ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:EASTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:595 PEBBLESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:WI
Mailing Address - Zip Code:54155-9386
Mailing Address - Country:US
Mailing Address - Phone:252-571-5696
Mailing Address - Fax:
Practice Address - Street 1:650 CENTENNIAL CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:WI
Practice Address - Zip Code:54155-8989
Practice Address - Country:US
Practice Address - Phone:920-544-5041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3302-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant