Provider Demographics
NPI:1598002644
Name:ROBERTSON, ELIZABETH RISTINE (LMT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RISTINE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1016 SE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2513
Mailing Address - Country:US
Mailing Address - Phone:503-226-4611
Mailing Address - Fax:
Practice Address - Street 1:1016 SE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2513
Practice Address - Country:US
Practice Address - Phone:503-226-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2991225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist