Provider Demographics
NPI:1134689201
Name:CARY, ELIZABETH ALICE (MSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALICE
Last Name:CARY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964-0168
Mailing Address - Country:US
Mailing Address - Phone:510-387-7447
Mailing Address - Fax:
Practice Address - Street 1:298 GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4895
Practice Address - Country:US
Practice Address - Phone:510-387-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA732441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty