Provider Demographics
NPI: | 1376772673 |
---|---|
Name: | ROBERTS, ELIZABETH DIANE (MS, LMFT) |
Entity Type: | Individual |
Prefix: | MISS |
First Name: | ELIZABETH |
Middle Name: | DIANE |
Last Name: | ROBERTS |
Suffix: | |
Gender: | F |
Credentials: | MS, LMFT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 12150 PIGEON PASS RD |
Mailing Address - Street 2: | C123 |
Mailing Address - City: | MORENO VALLEY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92557-6967 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 951-235-4115 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 747 N. EUCLID AVE |
Practice Address - Street 2: | |
Practice Address - City: | ONTARIO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91762-2878 |
Practice Address - Country: | US |
Practice Address - Phone: | 951-210-1235 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-07-08 |
Last Update Date: | 2016-10-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101YA0400X, 101YM0800X | ||
CA | LMFT92430 | 106H00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |