Healthcare Provider Details

I. General information

NPI: 1104042647
Provider Name (Legal Business Name): ELISHA M WATERS BA, CADCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9670 SW BEAVERTON HILLSDALE HWY
PORTLAND OR
97282
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-9494
  • Fax: 503-626-9494
Mailing address:
  • Phone: 503-626-9494
  • Fax: 503-646-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number060746
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: