Provider Demographics
NPI:1801930730
Name:FACKLER, ELIZABETH (DPT)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:FACKLER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:4610 CHAMBERLAIN LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-1160
Practice Address - Country:US
Practice Address - Phone:502-618-8200
Practice Address - Fax:502-618-8201
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0049252251X0800X
KY4925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000484220OtherANTHEM PROVIDER ID
KYKY4925OtherKY STATE LICENSE
KY0942503Medicare PIN