Provider Demographics
NPI:1649063116
Name:ANDERSEN, ELIJAH (CRM)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10117 SE SUNNYSIDE RD # F1217
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7708
Mailing Address - Country:US
Mailing Address - Phone:503-740-1971
Mailing Address - Fax:503-771-2486
Practice Address - Street 1:1217 NE BURNSIDE RD STE 701
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5770
Practice Address - Country:US
Practice Address - Phone:503-740-1971
Practice Address - Fax:503-771-2436
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-CRM3164101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)