Provider Demographics
NPI:1881809739
Name:BLACK, ELIZABETH (BETH) (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH (BETH)
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:E
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:900 8TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-764-0396
Mailing Address - Fax:
Practice Address - Street 1:8100 CONSTITUTION PL NE
Practice Address - Street 2:STE 120 PRESBYTERIAN HOME HEALTHCARE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-938-6994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist