Provider Demographics
NPI:1982130522
Name:THELISDORT, MOLLY ELIZABETH (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:THELISDORT
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ELIZABETH
Other - Last Name:LANGTEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7816 SW RUBY TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4644
Mailing Address - Country:US
Mailing Address - Phone:214-507-8677
Mailing Address - Fax:
Practice Address - Street 1:1110 SE ALDER ST
Practice Address - Street 2:ST #201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2400
Practice Address - Country:US
Practice Address - Phone:503-477-5051
Practice Address - Fax:503-954-2374
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4073175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath