Provider Demographics
NPI:1790094209
Name:DEATS, ELIZABETH BLUE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BLUE
Last Name:DEATS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W MENDENHALL ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3449
Mailing Address - Country:US
Mailing Address - Phone:419-618-3274
Mailing Address - Fax:
Practice Address - Street 1:205 N TRACY AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3564
Practice Address - Country:US
Practice Address - Phone:406-587-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2375PTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant