Provider Demographics
NPI:1629422217
Name:HAVERSTOCK, ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HAVERSTOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 HIGHWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1631
Mailing Address - Country:US
Mailing Address - Phone:219-513-8311
Mailing Address - Fax:708-479-2112
Practice Address - Street 1:2906 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:219-513-8311
Practice Address - Fax:708-479-2112
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist