Healthcare Provider Details

I. General information

NPI: 1649063116
Provider Name (Legal Business Name): ELIJAH ANDERSEN CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 701
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

10117 SE SUNNYSIDE RD # F1217
CLACKAMAS OR
97015-7708
US

V. Phone/Fax

Practice location:
  • Phone: 503-740-1971
  • Fax: 503-771-2436
Mailing address:
  • Phone: 503-740-1971
  • Fax: 503-771-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-CRM3164
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: