Provider Demographics
NPI:1295176840
Name:SHANKS, ELIZABETH ANN (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:SHANKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SHANKS
Other - Last Name:SURBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1171 OCEAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3421
Mailing Address - Country:US
Mailing Address - Phone:228-875-4000
Mailing Address - Fax:228-875-4051
Practice Address - Street 1:4387 LEISURE TIME DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3242
Practice Address - Country:US
Practice Address - Phone:228-255-3533
Practice Address - Fax:228-255-3536
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist