Basic Information
| Provider Information | |||||||||
| NPI: | 1689087041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERTH-DAVIS | ||||||||
| FirstName: | ELIZA | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17355 BOONES FERRY RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970355202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036350844 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2014 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 20653 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0330373 | 01 | OR | WA L&I | OTHER |