Provider Demographics
NPI:1477099000
Name:SMITH, LIZZ VANWILGEN (PT)
Entity Type:Individual
Prefix:
First Name:LIZZ
Middle Name:VANWILGEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:VANWILGEN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:146 PIERREPONT ST APT 8C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2840
Mailing Address - Country:US
Mailing Address - Phone:917-912-3980
Mailing Address - Fax:
Practice Address - Street 1:1133 BROADWAY STE 1211
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7963
Practice Address - Country:US
Practice Address - Phone:917-912-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014141-02251X0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program