Basic Information
Provider Information | |||||||||
NPI: | 1376998989 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIXER | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANTKOWSKI | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR/L | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7591 TYLERS PLACE BLVD | ||||||||
Address2: |   | ||||||||
City: | WEST CHESTER | ||||||||
State: | OH | ||||||||
PostalCode: | 450696308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137556600 | ||||||||
FaxNumber: | 5137553762 | ||||||||
Practice Location | |||||||||
Address1: | 7591 TYLERS PLACE BLVD | ||||||||
Address2: |   | ||||||||
City: | WEST CHESTER | ||||||||
State: | OH | ||||||||
PostalCode: | 45069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137556600 | ||||||||
FaxNumber: | 5137553762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2016 | ||||||||
LastUpdateDate: | 08/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 10238 | NC | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | OT010181 | OH | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7201016 | 05 | NC |   | MEDICAID | AB7360731 | 01 | OH | MEDICARE PIN | OTHER | 2187155 | 05 | OH |   | MEDICAID | 0788A | 01 | NC | BCBS | OTHER |