Provider Demographics
NPI:1205274156
Name:GREGORY, ELIZABETH MARIE (MA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 SW 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3618
Mailing Address - Country:US
Mailing Address - Phone:503-200-4746
Mailing Address - Fax:
Practice Address - Street 1:5319 SW WESTGATE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2411
Practice Address - Country:US
Practice Address - Phone:503-330-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2804101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health