Provider Demographics
NPI:1649429317
Name:ALLEN-RACICOT, ELIZABETH MARIE (LMP)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:ALLEN-RACICOT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:731 BURNELL AVE.
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4985
Mailing Address - Country:US
Mailing Address - Phone:208-798-3215
Mailing Address - Fax:
Practice Address - Street 1:1013 BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:509-751-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022912174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist