Healthcare Provider Details

I. General information

NPI: 1114322534
Provider Name (Legal Business Name): ELIZABETH FORMA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 SUNSET DR
LA GRANDE OR
97850-1269
US

IV. Provider business mailing address

PO BOX 3290
LA GRANDE OR
97850-7290
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-1437
  • Fax: 541-963-1890
Mailing address:
  • Phone: 541-963-8421
  • Fax: 541-963-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41633
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62036
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: