Provider Demographics
NPI:1720664972
Name:MATHISEN, ELIZABETH ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:MATHISEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2159
Mailing Address - Street 2:300 W MAIN ST
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210
Mailing Address - Country:US
Mailing Address - Phone:410-707-3656
Mailing Address - Fax:
Practice Address - Street 1:837 VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-4733
Practice Address - Country:US
Practice Address - Phone:410-707-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist