Provider Demographics
NPI:1265872733
Name:AVERITT, ELISE MIRIAM
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MIRIAM
Last Name:AVERITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:MIRIAM
Other - Last Name:LEATHERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9616 PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7257
Mailing Address - Country:US
Mailing Address - Phone:269-250-8200
Mailing Address - Fax:
Practice Address - Street 1:9616 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7257
Practice Address - Country:US
Practice Address - Phone:269-250-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other