Healthcare Provider Details

I. General information

NPI: 1639062375
Provider Name (Legal Business Name): ELIZABETH RAE DUB LAT, ATC, PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 S WASHINGTON ST
GRAND FORKS ND
58201-6337
US

IV. Provider business mailing address

451 N 51ST ST
GRAND FORKS ND
58203-2664
US

V. Phone/Fax

Practice location:
  • Phone: 701-757-3045
  • Fax:
Mailing address:
  • Phone: 218-791-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2826
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number912-21
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: