Provider Demographics
NPI:1700818069
Name:GOLDSMITH, ELLEN (LAC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11221
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-0221
Mailing Address - Country:US
Mailing Address - Phone:503-230-8973
Mailing Address - Fax:503-230-8978
Practice Address - Street 1:111 NE JESSUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-2517
Practice Address - Country:US
Practice Address - Phone:503-230-8973
Practice Address - Fax:503-230-8978
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00442171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182359Medicaid