Provider Demographics
NPI:1275184996
Name:WELCH, ELISABETH WYKOFF
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:WYKOFF
Last Name:WELCH
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 1:3071 EARLMAR DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4631
Mailing Address - Country:US
Mailing Address - Phone:949-378-5064
Mailing Address - Fax:
Practice Address - Street 1:3071 EARLMAR DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4631
Practice Address - Country:US
Practice Address - Phone:949-378-5064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT42236106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist