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
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
CALMFT92430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health