Provider Demographics
NPI:1457646838
Name:ELLIOTT, LORETTA ELLEN (LMT)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:ELLEN
Last Name:ELLIOTT
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 1:12085 SW 135TH AVE. APT.58
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1617
Mailing Address - Country:US
Mailing Address - Phone:503-880-6730
Mailing Address - Fax:
Practice Address - Street 1:12085 SW 135TH AVE APT 58
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-1617
Practice Address - Country:US
Practice Address - Phone:503-880-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14447225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist