Healthcare Provider Details

I. General information

NPI: 1770573354
Provider Name (Legal Business Name): SUSAN ELMORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 SW COLUMBIA ST
PORTLAND OR
97201-6025
US

IV. Provider business mailing address

1776 SW MADISON ST
PORTLAND OR
97205-1715
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-2641
  • Fax: 503-261-1654
Mailing address:
  • Phone: 503-231-2641
  • Fax: 503-231-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberMD19811
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: