Provider Demographics
NPI:1255704482
Name:BRO, ELSA
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:BRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1272
Mailing Address - Country:US
Mailing Address - Phone:541-490-8405
Mailing Address - Fax:
Practice Address - Street 1:5524 SE OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1272
Practice Address - Country:US
Practice Address - Phone:541-490-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60598165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist