Provider Demographics
NPI:1679741094
Name:AUGUSTINE, ELIZABETH MABLE (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MABLE
Last Name:AUGUSTINE
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 1:307 N CALLE DEL CHANCERO
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-3019
Mailing Address - Country:US
Mailing Address - Phone:520-574-2364
Mailing Address - Fax:
Practice Address - Street 1:101 S LA CANADA DR # 47
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2603
Practice Address - Country:US
Practice Address - Phone:520-207-9345
Practice Address - Fax:520-207-9345
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ 104140OtherGROUP LEGACY