Provider Demographics
NPI:1508118563
Name:CANNON, ELIZABETH JANE (LMBT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:CANNON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 NW SAVIER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2415
Mailing Address - Country:US
Mailing Address - Phone:706-410-0982
Mailing Address - Fax:
Practice Address - Street 1:2303 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1655
Practice Address - Country:US
Practice Address - Phone:503-213-6907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11670225700000X
GAMT008046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist