Provider Demographics
NPI:1033422068
Name:REICH, ELISA DORI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:DORI
Last Name:REICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11965 VENICE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3979
Mailing Address - Country:US
Mailing Address - Phone:888-724-0040
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3979
Practice Address - Country:US
Practice Address - Phone:888-724-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA26123103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program