Provider Demographics
NPI:1295385136
Name:GOLDSTEIN, ELISSA BETH
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:BETH
Last Name:GOLDSTEIN
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 1:4428 TUJUNGA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2073
Mailing Address - Country:US
Mailing Address - Phone:917-568-1231
Mailing Address - Fax:
Practice Address - Street 1:1010 N CENTRAL AVE STE 310
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2937
Practice Address - Country:US
Practice Address - Phone:818-724-9770
Practice Address - Fax:818-484-2991
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114867106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty