Provider Demographics
NPI:1609148642
Name:THELIN, ELYSSA
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:
Last Name:THELIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229
Mailing Address - Country:US
Mailing Address - Phone:503-645-3581
Mailing Address - Fax:503-459-4495
Practice Address - Street 1:4925 N ALBINA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2609
Practice Address - Country:US
Practice Address - Phone:503-442-5319
Practice Address - Fax:503-459-4495
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health