Provider Demographics
NPI:1073378741
Name:WETTLAUFER, ELIZABETH PENN (SUDRC16443)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PENN
Last Name:WETTLAUFER
Suffix:
Gender:F
Credentials:SUDRC16443
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3119
Mailing Address - Country:US
Mailing Address - Phone:213-351-2806
Mailing Address - Fax:
Practice Address - Street 1:2307 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3119
Practice Address - Country:US
Practice Address - Phone:213-351-2806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADTP16443101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)