Provider Demographics
NPI:1003838079
Name:ISENBERG, ELLIOTT (PHD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:ISENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SAN JOSE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3052
Mailing Address - Country:US
Mailing Address - Phone:415-695-0499
Mailing Address - Fax:
Practice Address - Street 1:115 SAN JOSE AVE APT 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3052
Practice Address - Country:US
Practice Address - Phone:415-695-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11202103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY112020Medicaid
CA0PL112020Medicare ID - Type UnspecifiedPSYCHOLOGIST