Provider Demographics
NPI:1881812303
Name:BOBO, ELIZABETH ANN
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:BOBO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LIBBY
Other - Middle Name:ANN
Other - Last Name:BOBO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3521 SAVOY CIR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5267
Mailing Address - Country:US
Mailing Address - Phone:270-994-7751
Mailing Address - Fax:270-441-7877
Practice Address - Street 1:5286 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7466
Practice Address - Country:US
Practice Address - Phone:270-441-7877
Practice Address - Fax:270-441-7877
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
KY200119099222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist