Basic Information
| Provider Information | |||||||||
| NPI: | 1063775799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELSTAD | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | STRACH | ||||||||
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| Credential: | CSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 NW CORNELL RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972295442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036909605 | ||||||||
| Practice Location | |||||||||
| Address1: | 4105 SE INTERNATIONAL WAY STE 501 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972228855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036909605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 54067 | TX | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | A3195 | OR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.