Provider Demographics
NPI:1508193871
Name:FERTIG, ELIZABETH RA (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RA
Last Name:FERTIG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:FERTIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:7150 CORVALLIS RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-9788
Mailing Address - Country:US
Mailing Address - Phone:503-838-2291
Mailing Address - Fax:
Practice Address - Street 1:7150 CORVALLIS RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-9788
Practice Address - Country:US
Practice Address - Phone:503-838-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR476804225X00000X, 225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist