Healthcare Provider Details

I. General information

NPI: 1043717705
Provider Name (Legal Business Name): ELIZABETH ANNE OLORENSHAW DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 EASTLAND DR
TWIN FALLS ID
83301-6747
US

IV. Provider business mailing address

1053 EASTLAND DR
TWIN FALLS ID
83301-6747
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-9011
  • Fax: 208-934-9014
Mailing address:
  • Phone: 208-736-9011
  • Fax: 208-934-9014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-5516
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-5516
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: