Provider Demographics
NPI:1851772024
Name:AULT, ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:AULT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 CAMPBELL BLVD
Mailing Address - Street 2:STE. 130A
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5908
Mailing Address - Country:US
Mailing Address - Phone:443-442-2810
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:STE. 130A
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-442-2810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4222225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant