Provider Demographics
NPI:1871332353
Name:STOCKWELL, ELIZABETH MARIE (AUD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-6592
Mailing Address - Fax:
Practice Address - Street 1:1753 FULTON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1927
Practice Address - Country:US
Practice Address - Phone:574-293-9448
Practice Address - Fax:574-293-9480
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002858A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300092487Medicaid