Provider Demographics
NPI:1295125425
Name:TARZWELL, ELISABETH KATHLYN KORNBERG (LPC)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:KATHLYN KORNBERG
Last Name:TARZWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:KATHLYN
Other - Last Name:KORNBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2684
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional