Provider Demographics
NPI:1497264428
Name:FORD, ELIZABETH KATHLEEN (LMT,CA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KATHLEEN
Last Name:FORD
Suffix:
Gender:F
Credentials:LMT,CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2914
Mailing Address - Country:US
Mailing Address - Phone:541-963-4068
Mailing Address - Fax:
Practice Address - Street 1:1704 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2914
Practice Address - Country:US
Practice Address - Phone:541-963-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist