Provider Demographics
NPI:1598028029
Name:BOARD, ELIZABETH ANNE (MSED)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:BOARD
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CAVE HOLW
Mailing Address - Street 2:
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-9568
Mailing Address - Country:US
Mailing Address - Phone:585-301-2231
Mailing Address - Fax:
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1434
Practice Address - Country:US
Practice Address - Phone:585-377-2230
Practice Address - Fax:585-377-2243
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY577837051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist