Provider Demographics
NPI:1710023825
Name:RAUCKHORST, LIZABETH ANNE (MS CCC- SLP)
Entity Type:Individual
Prefix:MRS
First Name:LIZABETH
Middle Name:ANNE
Last Name:RAUCKHORST
Suffix:
Gender:F
Credentials:MS CCC- SLP
Other - Prefix:MS
Other - First Name:LIZABETH
Other - Middle Name:ANNE
Other - Last Name:MARRETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:8503 WAGON WHEEL LN
Mailing Address - Street 2:
Mailing Address - City:BAYONET POINT
Mailing Address - State:FL
Mailing Address - Zip Code:34667-2582
Mailing Address - Country:US
Mailing Address - Phone:727-534-9551
Mailing Address - Fax:
Practice Address - Street 1:14100 FIVAY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7180
Practice Address - Country:US
Practice Address - Phone:727-869-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889769700Medicaid