Healthcare Provider Details

I. General information

NPI: 1548591183
Provider Name (Legal Business Name): ELIZABETH CHAPMAN COSTA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ESD 112 2500 NE 65TH AVENUE
VANCOUVER WA
98661-5506
US

IV. Provider business mailing address

4334 NE CESAR E CHAVEZ BLVD
PORTLAND OR
97211-8230
US

V. Phone/Fax

Practice location:
  • Phone: 360-750-7500
  • Fax:
Mailing address:
  • Phone: 646-942-1224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6131
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number60167341
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: