Provider Demographics
NPI:1669208310
Name:SIRON, ELIJAH
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:SIRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7739 SW CAPITOL HWY STE 260
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2571
Mailing Address - Country:US
Mailing Address - Phone:541-640-0016
Mailing Address - Fax:
Practice Address - Street 1:7739 SW CAPITOL HWY STE 260
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2571
Practice Address - Country:US
Practice Address - Phone:541-640-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health