Healthcare Provider Details

I. General information

NPI: 1528473295
Provider Name (Legal Business Name): ELIZABETH RAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8232
  • Fax: 619-542-4060
Mailing address:
  • Phone: 619-692-8232
  • Fax: 619-542-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number53534
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: