Provider Demographics
NPI:1033351838
Name:ELZEA, PHYLLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ELZEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 SW CEDAR HILLS BLVD
Mailing Address - Street 2:#213
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1354
Mailing Address - Country:US
Mailing Address - Phone:503-241-2276
Mailing Address - Fax:
Practice Address - Street 1:10700 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:SUITE 525
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3019
Practice Address - Country:US
Practice Address - Phone:503-241-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-26
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR#721101YM0800X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OREIN 27-0049633OtherUS DEPARTMENT OF TREASURY