Provider Demographics
NPI:1386982452
Name:HILLSTROM, ELIJAH MATTHEW (CPED)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:MATTHEW
Last Name:HILLSTROM
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 NE 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3426
Mailing Address - Country:US
Mailing Address - Phone:360-635-8079
Mailing Address - Fax:360-450-2236
Practice Address - Street 1:4903 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2546
Practice Address - Country:US
Practice Address - Phone:360-635-8079
Practice Address - Fax:360-450-2236
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACPED3653224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist