Provider Demographics
NPI:1912300294
Name:GRANER, ELISE (QMHP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GRANER
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11035 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2553
Mailing Address - Country:US
Mailing Address - Phone:503-258-4202
Mailing Address - Fax:503-736-9759
Practice Address - Street 1:11035 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2553
Practice Address - Country:US
Practice Address - Phone:503-258-4202
Practice Address - Fax:503-736-9759
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid