Provider Demographics
NPI:1740791037
Name:PEDERSEN, EIZABETH MICHELE (LMT)
Entity Type:Individual
Prefix:
First Name:EIZABETH
Middle Name:MICHELE
Last Name:PEDERSEN
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 1:2904 E MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4740
Mailing Address - Country:US
Mailing Address - Phone:443-745-3959
Mailing Address - Fax:
Practice Address - Street 1:333 NE RUSSELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3762
Practice Address - Country:US
Practice Address - Phone:503-289-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist