Healthcare Provider Details

I. General information

NPI: 1619108024
Provider Name (Legal Business Name): ELKA JANIS GRISHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SW MARLOW AVE SUITE 208
PORTLAND OR
97225-5185
US

IV. Provider business mailing address

1815 SW MARLOW AVE SUITE 208
PORTLAND OR
97225-5185
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-7979
  • Fax:
Mailing address:
  • Phone: 503-297-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL4377
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: