Provider Demographics
NPI:1043777410
Name:GERKEN, ELOISE
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:
Last Name:GERKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 MARTIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8610
Mailing Address - Country:US
Mailing Address - Phone:707-806-0666
Mailing Address - Fax:
Practice Address - Street 1:1734 JEFFERSON ST STE C
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-1746
Practice Address - Country:US
Practice Address - Phone:707-299-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CA120666106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst