Provider Demographics
NPI:1942510821
Name:MATTICE, ELISA JANE (BS, LMT)
Entity Type:Individual
Prefix:MISS
First Name:ELISA
Middle Name:JANE
Last Name:MATTICE
Suffix:
Gender:F
Credentials:BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 SE 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-7513
Mailing Address - Country:US
Mailing Address - Phone:503-438-8017
Mailing Address - Fax:
Practice Address - Street 1:32598 PITTSBURG RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-9124
Practice Address - Country:US
Practice Address - Phone:503-438-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist