Provider Demographics
NPI:1679024970
Name:GORDON, ELIZABETH (LAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3109 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1812
Mailing Address - Country:US
Mailing Address - Phone:971-341-9546
Mailing Address - Fax:971-275-1446
Practice Address - Street 1:3109 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1812
Practice Address - Country:US
Practice Address - Phone:971-341-9546
Practice Address - Fax:971-275-1446
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC179845171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist