Provider Demographics
NPI:1083979454
Name:LIAKOS, CONNIE L (RD, LD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:LIAKOS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:EVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:2701 NW VAUGHN ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-227-0671
Mailing Address - Fax:503-227-4589
Practice Address - Street 1:7150 SW DARTMOUTH ST.
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-968-3480
Practice Address - Fax:503-227-4589
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD000122133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654435Medicaid