=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699204974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH ELLEN IZBOTSKY PT, MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S BUENA VISTA BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-802-4038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 S BUENA VISTA ST
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-802-4038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 29192
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------