Provider Demographics
NPI:1508129941
Name:MINK, ELIZABETH E (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:E
Last Name:MINK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8940 WALNUT HILL RD APT 302
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 AIRWAYS PL
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5885
Practice Address - Country:US
Practice Address - Phone:662-349-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist