1124485495 NPI number — MRS. ELISABETH ANNE BALCOM M.A.,CCC/SLP

Table of content: MRS. ELISABETH ANNE BALCOM M.A.,CCC/SLP (NPI 1124485495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124485495 NPI number — MRS. ELISABETH ANNE BALCOM M.A.,CCC/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALCOM
Provider First Name:
ELISABETH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.,CCC/SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JORGENSEN
Provider Other First Name:
BETSY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124485495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 SE INTERNATIONAL WAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97222-4628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12778 ROAD 37 1/2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93636-8757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-430-8239
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP16633 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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