Basic Information
| Provider Information | |||||||||
| NPI: | 1154679710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN WINKLE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROWLEY | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10190 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234500190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004775240 | ||||||||
| FaxNumber: | 7574636572 | ||||||||
| Practice Location | |||||||||
| Address1: | 8303 DODGE ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023545048 | ||||||||
| FaxNumber: | 4023542585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 002236 | IA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 1582 | NE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 002236 | 01 | IA | IA LICENSE | OTHER | 10026075400 | 05 | NE | MEDICAID | 1582 | 01 | NE | NE LICENSE | OTHER |