Provider Demographics
NPI:1104202381
Name:FONG, ELIZABETH REID (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:REID
Last Name:FONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2305
Mailing Address - Country:US
Mailing Address - Phone:310-545-5762
Mailing Address - Fax:
Practice Address - Street 1:713 29TH ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2305
Practice Address - Country:US
Practice Address - Phone:310-545-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS22048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health