Provider Demographics
NPI:1093143307
Name:ESTACIO, ELISABETH (PT)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:ESTACIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:ESTACIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:17279 NW LA PALOMA LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7397
Mailing Address - Country:US
Mailing Address - Phone:818-281-6841
Mailing Address - Fax:
Practice Address - Street 1:15390 NW CORNELL RD
Practice Address - Street 2:SUITE 230
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5627
Practice Address - Country:US
Practice Address - Phone:971-245-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR064902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic