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General NPI Number Information
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NPI Number | 1982130522
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Entity Type | Individual
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Provider Name | MOLLY ELIZABETH THELISDORT N.D., L.AC.
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Gender | Female
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 1110 SE ALDER ST ST #201
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City | PORTLAND
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State | OR
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Zip | 97214-2400
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Country | US
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Telephone | 503-477-5051
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Fax | 503-954-2374
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Provider Business Mailing Address
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Address Line | 7816 SW RUBY TER
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City | PORTLAND
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State | OR
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Zip | 97219-4644
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Country | US
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Telephone | 214-507-8677
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175F00000X
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Taxonomy Name | Naturopath
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License Number | 4073
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License Number State | OR
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