Provider Demographics
NPI:1376910646
Name:POWELL, ELIZABETH REA (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:REA
Last Name:POWELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:REA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:900 LAFAYETTE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4966
Mailing Address - Country:US
Mailing Address - Phone:408-293-7767
Mailing Address - Fax:408-294-6595
Practice Address - Street 1:900 LAFAYETTE ST STE 105
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050
Practice Address - Country:US
Practice Address - Phone:408-293-7767
Practice Address - Fax:408-294-6595
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist