Provider Demographics
NPI:1093816043
Name:ELIZONDO, CYNTHIA MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2708
Mailing Address - Country:US
Mailing Address - Phone:651-695-1022
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 229N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
41-1576550OtherPRACTICE FED TAX ID#