Basic Information
| Provider Information | |||||||||
| NPI: | 1265992556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOLTZIN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 NW EXPRESSWAY STE 809 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059177160 | ||||||||
| FaxNumber: | 4059177161 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 NW EXPRESSWAY STE 809 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059177160 | ||||||||
| FaxNumber: | 4059177161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2019 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 698 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 698 | 05 | OK | MEDICAID |