Basic Information
| Provider Information | |||||||||
| NPI: | 1952650186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUDENHOFER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILBERT | ||||||||
| OtherFirstName: | ELIAZABETH | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648194 | ||||||||
| FaxNumber: | 2086671847 | ||||||||
| Practice Location | |||||||||
| Address1: | 14120 N NEWPORT HWY | ||||||||
| Address2: | STE. B | ||||||||
| City: | MEAD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990218600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094684861 | ||||||||
| FaxNumber: | 5094682101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2012 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-7225 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60290653 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01207552 | 01 | WA | RR MEDICARE | OTHER | 1952650186 | 05 | WA | MEDICAID |