Provider Demographics
NPI:1902215858
Name:PFOTENHAUER, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:PFOTENHAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:BRAZIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17291 IRVINE BLVD., SUITE 325
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:714-730-7700
Mailing Address - Fax:714-730-7766
Practice Address - Street 1:17291 IRVINE BLVD,, SUITE 325
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-730-7700
Practice Address - Fax:714-730-7766
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist