Provider Demographics
NPI:1932461845
Name:AUGUSTINE, ELIZABETH LEANN (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEANN
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 HUFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:WINONA LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46590-2065
Mailing Address - Country:US
Mailing Address - Phone:574-377-0560
Mailing Address - Fax:
Practice Address - Street 1:1500 PROVIDENT DR STE C
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3297
Practice Address - Country:US
Practice Address - Phone:574-372-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001368A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer