Healthcare Provider Details

I. General information

NPI: 1255649042
Provider Name (Legal Business Name): ELIZABETH WEIL LEBRON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 CAM DEL MONTE REY STE A2
SANTA FE NM
87505-3961
US

IV. Provider business mailing address

44 SUNDANCE DR
SANTA FE NM
87506-8551
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-9940
  • Fax:
Mailing address:
  • Phone: 505-983-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number3887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: