Provider Demographics
NPI:1164134615
Name:LUNA, ELISSA SOPHIA
Entity Type:Individual
Prefix:MISS
First Name:ELISSA
Middle Name:SOPHIA
Last Name:LUNA
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 1:12443 LEWIS STREET #201
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840
Mailing Address - Country:US
Mailing Address - Phone:714-748-4440
Mailing Address - Fax:
Practice Address - Street 1:12443 LEWIS STREET, #201
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840
Practice Address - Country:US
Practice Address - Phone:714-748-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician