Provider Demographics
NPI:1689223984
Name:HARGIS, ELSIE VAUGHN (LMT)
Entity Type:Individual
Prefix:
First Name:ELSIE
Middle Name:VAUGHN
Last Name:HARGIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ROLLINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-9358
Mailing Address - Country:US
Mailing Address - Phone:719-231-5280
Mailing Address - Fax:
Practice Address - Street 1:755 VANDERCOOK WAY STE 101A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4050
Practice Address - Country:US
Practice Address - Phone:360-577-0294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60964071225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist