Provider Demographics
NPI:1700316312
Name:OTTERBEIN, ELIZABETH STABLEY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:STABLEY
Last Name:OTTERBEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11113 RESEARCH BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5297
Mailing Address - Country:US
Mailing Address - Phone:512-324-6575
Mailing Address - Fax:512-324-6576
Practice Address - Street 1:11113 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5297
Practice Address - Country:US
Practice Address - Phone:512-324-6575
Practice Address - Fax:512-324-6576
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX114349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program