Provider Demographics
NPI:1124485495
Name:BALCOM, ELISABETH ANNE (MA,CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:ANNE
Last Name:BALCOM
Suffix:
Gender:F
Credentials:MA,CCC/SLP
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12778 ROAD 37 1/2
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8757
Practice Address - Country:US
Practice Address - Phone:559-430-8239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP16633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist