Provider Demographics
NPI:1265857767
Name:GOTTFRED, ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GOTTFRED
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7096 ELBA WAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2017
Mailing Address - Country:US
Mailing Address - Phone:926-967-2911
Mailing Address - Fax:
Practice Address - Street 1:739 MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6672
Practice Address - Country:US
Practice Address - Phone:925-967-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85609106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist