Basic Information
| Provider Information | |||||||||
| NPI: | 1518038884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DREWITZ | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOSENG | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD. LP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550216337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073343921 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550216337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073343921 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP5863 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.