Provider Demographics
NPI:1912624107
Name:COONS, ELIZABETH NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:COONS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-2556
Mailing Address - Country:US
Mailing Address - Phone:317-509-4328
Mailing Address - Fax:
Practice Address - Street 1:8400 CLEARVISTA PL # 3D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3700
Practice Address - Country:US
Practice Address - Phone:317-509-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005515A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty