Provider Demographics
NPI:1336371640
Name:SHALALA, ELIZEBETH J (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZEBETH
Middle Name:J
Last Name:SHALALA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ELIZEBETH
Other - Middle Name:J
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:969 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4985
Mailing Address - Country:US
Mailing Address - Phone:321-225-9788
Mailing Address - Fax:
Practice Address - Street 1:11 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3590
Practice Address - Country:US
Practice Address - Phone:321-225-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3019910435246RP1900X
NY3019910444246Z00000X
NY3019910440246Z00000X
FLMA103702225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other