Healthcare Provider Details

I. General information

NPI: 1699250118
Provider Name (Legal Business Name): ELISA ABALLAY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISA STOKER

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 RIVER RD S STE 200
SALEM OR
97302-3677
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-4824
  • Fax: 503-370-2545
Mailing address:
  • Phone: 503-443-6156
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12458
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: