Provider Demographics
NPI:1366043101
Name:FOSTER, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18450 NE RIBBON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6566
Mailing Address - Country:US
Mailing Address - Phone:503-476-2511
Mailing Address - Fax:
Practice Address - Street 1:4040 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1952
Practice Address - Country:US
Practice Address - Phone:503-493-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR63874OtherSTATE OF OREGON BOARD OF PHYSICAL THERAPY
CA299256OtherPHYSICAL THERAPY BOARD OF CALIFORNIA