Provider Demographics
NPI:1427376029
Name:LOOMIS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LOOMIS
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 1:10695 E STANTON RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MI
Mailing Address - Zip Code:48818-8622
Mailing Address - Country:US
Mailing Address - Phone:989-763-6689
Mailing Address - Fax:
Practice Address - Street 1:917 BEVILLE RD STE G
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1736
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2075730225200000X
MI5502002224225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant