Provider Demographics
NPI:1437626124
Name:LAGAZO, ELIZABETH RAE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RAE
Last Name:LAGAZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:RAE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 SHOUP AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3657
Mailing Address - Country:US
Mailing Address - Phone:208-528-4071
Mailing Address - Fax:
Practice Address - Street 1:150 SHOUP AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3657
Practice Address - Country:US
Practice Address - Phone:208-528-4071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist