Provider Demographics
NPI:1104042647
Name:WATERS, ELISHA M (BA, CADCI)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:M
Last Name:WATERS
Suffix:
Gender:F
Credentials:BA, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-626-9494
Mailing Address - Fax:503-646-8401
Practice Address - Street 1:9670 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97282
Practice Address - Country:US
Practice Address - Phone:503-626-9494
Practice Address - Fax:503-626-9494
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR060746101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)