=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033734165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH CAVENDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2020
-----------------------------------------------------
Last Update Date | 05/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2011 BROADWAY ST STE 130
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77581-5945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-940-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 MONICA LN
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78664-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-940-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 1262291
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------