Provider Demographics
NPI:1619579869
Name:INBODEN, ELIZABETH (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:INBODEN
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5192 N 400TH ST
Mailing Address - Street 2:
Mailing Address - City:OBLONG
Mailing Address - State:IL
Mailing Address - Zip Code:62449-3926
Mailing Address - Country:US
Mailing Address - Phone:618-553-4391
Mailing Address - Fax:
Practice Address - Street 1:11218 N 200TH ST
Practice Address - Street 2:
Practice Address - City:OBLONG
Practice Address - State:IL
Practice Address - Zip Code:62449-2816
Practice Address - Country:US
Practice Address - Phone:618-553-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.021861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist