Basic Information
Provider Information | |||||||||
NPI: | 1578615902 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TAIBE | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S.P.T. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3020 CHILDRENS WAY | ||||||||
Address2: | MC 5068 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921234223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585761700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3020 CHILDRENS WAY | ||||||||
Address2: | MC 5068 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921234223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585761700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2007 | ||||||||
LastUpdateDate: | 09/23/2014 | ||||||||
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 | 225100000X | PT 29942 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 2305206702 | VA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | PT 29942 | 01 | CA | PHYSICAL THERAPIST | OTHER | 2305206702 | 01 | VA | PT | OTHER |