Provider Demographics
NPI:1861296758
Name:RICKERT, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:RICKERT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 N LAMAR BLVD
Mailing Address - Street 2:APT 246
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751
Mailing Address - Country:US
Mailing Address - Phone:724-988-9749
Mailing Address - Fax:
Practice Address - Street 1:2600 E PFLUGERVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-5999
Practice Address - Country:US
Practice Address - Phone:512-654-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81772231H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist