Provider Demographics
NPI:1164040333
Name:BROCKWAY, ELISA (LMT)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 NE 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6747
Mailing Address - Country:US
Mailing Address - Phone:971-344-4223
Mailing Address - Fax:
Practice Address - Street 1:530 1ST ST STE B2
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3248
Practice Address - Country:US
Practice Address - Phone:971-344-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7964225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist