Provider Demographics
NPI:1720471329
Name:DAVIS, ELIZABETH ANNE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 VENICE BEACH WAY
Mailing Address - Street 2:UNIT 4
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-2490
Mailing Address - Country:US
Mailing Address - Phone:406-589-6163
Mailing Address - Fax:
Practice Address - Street 1:1500 UNIVERSITY DR
Practice Address - Street 2:ATHLETIC DEPARTMENT
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0245
Practice Address - Country:US
Practice Address - Phone:406-657-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20000077912081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000007791OtherNATABOC
MTATR-LAT-LIC-867OtherMONTANA ATHLETIC TRAINING LICENSURE