Provider Demographics
NPI:1023648839
Name:KING, ELINA ELLA
Entity type:Individual
Prefix:
First Name:ELINA
Middle Name:ELLA
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELVIRA
Other - Middle Name:OLEGOVNA
Other - Last Name:NIKITINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:12511 SE RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3931
Practice Address - Country:US
Practice Address - Phone:503-761-2580
Practice Address - Fax:503-761-2584
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health