Provider Demographics
NPI:1508010455
Name:LAFAVE, ELIZABETH MARIE (RPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:LAFAVE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21638 REED RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5048
Mailing Address - Country:US
Mailing Address - Phone:315-786-0677
Mailing Address - Fax:
Practice Address - Street 1:1635 OHIO ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3032
Practice Address - Country:US
Practice Address - Phone:315-786-7285
Practice Address - Fax:315-786-7270
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008961-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist